Inspection on 21/11/05 for Birdhurst Gardens

This inspection was carried out on 21st November 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birdhurst Gardens 22/05/07

Birdhurst Gardens 09/05/06

Birdhurst Gardens 31/05/05

Birdhurst Gardens 26/07/04

Birdhurst Gardens 26/04/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Birdhurst Gardens 15 Birdhurst Gardens South Croydon Surrey CR2 7DT Lead Inspector James O`Hara Unannounced Inspection 21st November 2005 08:20 Birdhurst Gardens DS0000025755.V265279.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 Birdhurst Gardens DS0000025755.V265279.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. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Birdhurst Gardens Address 15 Birdhurst Gardens South Croydon Surrey CR2 7DT 020 8680 6876 020 8681 1649 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) Surrey Oaklands NHS Trust Mrs Ruwami Trabelsi Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st May 2005 Brief Description of the Service: Birdhurst Gardens is registered to provide care for up to nine adults with learning disabilities. There are currently seven service users living at the home. The home also provides respite care to four service users.Birdhurst Gardens is situated in a quite residential street of similar properties in south Croydon. The home is a large detached property built over three floors. Each of the service users has a single bedroom; there is also a communal lounge/dining room as well as, bathrooms, an office and kitchen. To the rear of the premises is a pleasant garden, which is well used in the summer months. The home has an outside laundry facility and parking to the front. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second inspection at the home this year. This unannounced inspection concentrated mainly on the previous requirements and recommendations set at the announced inspection on the 31st May 2005. Methods of inspection included previous experience of inspections at the home, a tour of the premises and observation of contact between staff and service users. Records examined included Person Centred Plans, risk assessments, staff training records, and correspondence in relation to service users health issues. The home manager was not present on the day of the inspection however a member of staff ably supported with the inspection process. The member of staff provided evidence were she could regarding the requirements and recommendations set at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: There were a total of twelve requirements and two recommendations set at the last inspection. The member of staff on shift was able to produce evidence that a number of these had been met however she was not able to provide evidence for six requirements and the two recommendations. As a result of this inspection four new requirements have been set. On the day of the inspection the service users were not able to attend their day services because there was no driver on shift, the service users had to spend the day at home. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 6 The member of staff said that this situation was a rare occurrence. None the less the home could do more to ensure that at all times arrangements are in place so that service users can attend their planned daytime activities. The home should do more to ensure that at all times service users are supported to attend these activities. In general staff at the home are well trained in the medical needs of the service users however all staff should be trained in epilepsy. The home should contact the Commission so that Criminal Records Bureau Checks and staffing information is inspected to evidence that staff vetting is occurring properly thus ensuring the protection of the service users. The home manager and another manager from another Surrey and Borders home have swapped homes. The new home manager needs to apply to the Commission to become the registered manager for the home. The inspector would like to thank the service users and staff for their support on the day of the inspection. 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. Birdhurst Gardens DS0000025755.V265279.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 Birdhurst Gardens DS0000025755.V265279.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): 0. Standards 1 and 2 were assessed as met at the last inspection. EVIDENCE: Birdhurst Gardens DS0000025755.V265279.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): 6, 7 and 9. Person Centred Plans indicate that service users and their representatives are fully involved so that they can express their wishes and plan for the future. The plans include detailed information on the service users needs and personal goals. However not all of the service users have completed a Person Centred Plan. EVIDENCE: Two service user files were examined. One service user has recently carried out a Person Centred Plan the other service user had a My Plan. The Person Centred Plan was completed indicating that the service user is fully involved. The My Plan was not dated and the member of staff was not sure when it had been completed. She stated that staff are in the process of carrying out Person Centred Plans for all of the service users. A requirement was set at the last inspection that the registered manager must ensure that the level of personal care support a service user needs and the service users preferred routines are recorded in the Person Centred Plans. The Plans examined did not indicate this information. The Person Centred Plans will be further examined at the next inspection. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 10 Both service users files had a section on risk assessments, it was noted that all risk assessments were reviewed on a regular basis. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 11 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. Standards 11, 12, 13, 14, 15, 16 and 17 were assessed at the last inspection. The home could do more to ensure that at all times provision is made so that all service users attend appropriate social activities, day centres and become part of the local community. EVIDENCE: On the day of the inspection the member of staff tried to arrange for transport to take the service users to the day service. The member of staff said that there were three drivers employed at the home but none of them were working that morning. One was working nights another was on annual leave and the other the home manager was working a late shift that day. The member of staff was not able to arrange for transport so all the service users had to spend the day at home. The member of staff said that this situation is a rare occurrence. None the less the home manager must ensure that at all times appropriate plans and arrangements are in place so that service users can attend their planned daytime activities. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 12 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 and 20. In general staff at the home are well trained in the medical needs of the service users however staff should be trained in epilepsy. EVIDENCE: As required at the last inspection the home has kept the Commission informed of any serious illness of service users at the home and the home has acquired a new cabinet suitable for storing medication. It was noted at the last inspection that one service user had been admitted to hospital. At that time the previous manager said that there was a discharge meeting to be held at the hospital to discuss if the home could still meet the needs of this service user. The previous manager reviewed all risk assessments and guidelines for staff to follow with the service users care manager in the event of the service user moving back into the home from the hospital. There was evidence in this service users file that indicated that the service user is being well supported with his medical, physical and mental health needs. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 13 A requirement was set at the last inspection that the registered manager ensures that all staff has training on epilepsy. One staff had attended training on the 22nd July 2005 on Stesolid Administration. The training certificate stated that one of the course objectives was to ensure knowledge and awareness of the relevant issues around epilepsy in learning disabilities and the use of Rectal Diazepam and other treatments. However there was no evidence to suggest that all staff has attended training on epilepsy. The new home manager must ensure that all members of staff attend training on epilepsy. The home manager should pay particular attention to this requirement. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 14 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): 0. Standards 22 and 23 were assessed as met at the last inspection. EVIDENCE: Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 15 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, 27 and 30. There have been some improvements to the home since the last inspection an effort has been made to ensure that service users live in a more homely and comfortable environment. Further improvements are planned. EVIDENCE: The overall impression when visiting this home is that it is homely, comfortable clean and hygienic. The home has purchased new settees are for the living room as required at the last inspection. As required at the last inspection sealant around the homes baths have been replaced and toilet seats have been replaced or tightened. The bath panel on the ground floor bath is loose and cracked. The new home manager must ensure that the bath panel on the ground floor bath is replaced. At the last inspection it was noted that the dining area contained suitable domestic tables however during that inspection the previous manager said that there are plans to purchase new chairs as some service users were using garden chairs to sit at the dining table. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 16 A requirement was set at that inspection that the registered manager ensure that new dining room chairs are purchased for the service users. The member of staff on shift stated that these had been ordered but she did not know when they would be delivered to the home. This requirement stands. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 17 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): 34 and 35. Standards 31, 32, 33, 34, 35 and 36 were assessed at the last inspection. The home has failed to contact the Commission so that Criminal Records Bureau Checks and staffing information is inspected to evidence that staff vetting is occurring properly thus ensuring the protection of the service users. EVIDENCE: The home manager was not available on the day of the inspection, the member of staff could not access staff files. The member of staff contacted the service manager to inform her that the home was being inspected. A requirement was set at the last inspection that the registered manager must write to the Commission for Social Care Inspection when she obtains staff the information as required in Regulation 19 (1) b and Schedule 2 National Minimum Standards and arrange a date for these to be inspected. The registered manager did not contact the Commission to arrange for this staff information to be inspected A requirement was set at the last inspection that the registered manager must write to the Commission for Social Care Inspection when she receives the other two members of staffs Criminal Records Bureau Checks and arrange a date for these to be inspected. The registered manager did not contact the Commission to arrange for Criminal Records Bureau Checks to be inspected. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 18 The service manager stated over the telephone that these Criminal Records Bureau Checks had been sent to the staff however not to the trust and as a result the staff in question has applied again for clearance. The new home manager must contact the Commission when she receives the Criminal Records Bureau Checks for two members of staffs and arrange a date for these to be inspected. A requirement was set at the last inspection that the registered manager must ensure that all staff has an annual appraisal. The member of staff on shift stated that she is having an annual appraisal however access to this information was restricted on the day of the inspection. This requirement will be assessed at the next inspection. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 19 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 and 42. There has been a change in the management at the home. The new manager managed another Surrey and Borders NHS Trust since 1997. EVIDENCE: The home manager was previously a registered manager at another of Surrey and Borders NHS Trust home. She and another registered manager from another Surrey and Borders home have swapped homes. The new home manager must apply to the Commission For Social Care Inspection to become the registered manager for the home. The registered person must give notice to the Commission if a person other than the registered person carries on or manages the home or a person ceases to carry on or manage the home. Staff training records indicate that staff has attended training on fire safety, food hygiene, moving and handling, first aid and health and safety. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 20 A recommendation was set at the last inspection that staff read, sign and date as evidence that they have read and understood all the homes new policies and procedures. The member of staff on shift showed evidence that some staff had signed new policy and procedures but not staff had done so. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 21 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 X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 2 X X 3 LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Birdhurst Gardens Score 3 2 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X 3 X DS0000025755.V265279.R01.S.doc Version 5.0 Page 22 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 YA19 Regulation 18 (1) c. Requirement The new home manager must ensure that all staff has training on epilepsy. This requirement is unmet from previous inspection 31st May 2005. The new home manager must ensure that new dining room chairs are purchased for the service users. This requirement is unmet from previous inspection 31st May 2005. The new home manager must ensure that at all times appropriate plans and arrangements are in place so that service users can attend their planned daytime activities. The new home manager must ensure that the bath panel on the ground floor bath is replaced. The new home manager must contact the Commission when she obtains staff the information as required in Regulation 19 (1) b and Schedule 2 National Minimum Standards and arrange a date for these to be inspected. This requirement is unmet DS0000025755.V265279.R01.S.doc Timescale for action 31/07/05 2. YA24 23 (2) g. 31/07/05 3. YA12 15. 21/11/05 4. YA27 23(2) b. 31/12/05 5. YA34 19(1) b. 21/11/05 Birdhurst Gardens Version 5.0 Page 23 6. YA34 19(1) b. 7. YA37 8(2). 8. YA6 15(1). 9. YA37 39(a and b). 10. YA35 18(1) c. from previous inspection 31st May 2005. The new home manager must contact the Commission when she receives the Criminal Records Bureau Checks for two members of staffs and arrange a date for these to be inspected. This requirement is unmet from previous inspection 31st May 2005. The new home manager must apply to the Commission For Social Care Inspection to become the registered manager for the home. The new home manager must ensure that the level of personal care support a service user needs and the service users preferred routines are recorded in the Person Centred Plans. This requirement is unmet from previous inspection 31st May 2005. The registered person must give notice to the Commission if a person other than the registered person carries on or manages the home or a person ceases to carry on or manage the home. The new home manager must ensure that all staff has an annual appraisal. This requirement from inspection 31st May 2005 could not be fully inspected. 21/11/05 21/11/05 31/07/05 21/11/05 31/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 24 1. 2. YA40 YA22 The inspector recommends that staff have to sign and date as evidence that they have read and understood all the homes new policies and procedures. It is recommended that the home send a copy of the complaints procedure to all of the service users relatives. Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Birdhurst Gardens DS0000025755.V265279.R01.S.doc Version 5.0 Page 26 - 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!