Inspection on 01/06/07 for Birdhurst Rise, 7

This inspection was carried out on 1st June 2007.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birdhurst Rise, 7 03/07/08

Birdhurst Rise, 7 15/01/08

Birdhurst Rise, 7 04/08/06

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 Rise, 7 7 Birdhurst Rise South Croydon Surrey CR2 7EG Lead Inspector Lee Willis Key Unannounced Inspection 1st June 2007 10:00 Birdhurst Rise, 7 DS0000066789.V339571.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 Birdhurst Rise, 7 DS0000066789.V339571.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. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birdhurst Rise, 7 Address 7 Birdhurst Rise South Croydon Surrey CR2 7EG 0208 681 2216 0208 688 1723 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.caremanagementgroup.com Care Management Group Limited Mrs Sarah Elizabeth Ann Brown Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th August 2006 Brief Description of the Service: 7 Birdhurst Rise is owned CMG a specialist provider care for adults with learning disabilities and behaviours that may challenge. The service provides accommodation and personal support for up to eight adults of either gender. Sarah Brown is the registered manager and has been in operational day-to-day control since March 2006. This detached Victorian property is situated in a quiet residential suburb to the South of Croydon. The service has its own transport and is within ten minutes of walk of several main line bus routes and a local train station. A variety of local shops, cafes, restaurants, and pubs are also within easy walking distance of the home. The property has eight single occupancy bedrooms all with en-suite facilities. Communal areas are largely located on the ground floor and comprise of a main lounge; separate dinning area/smoking room; a large open plan kitchen/dinner; spacious entrance hall, laundry room; and office. There is also a separate visitors room located on the top floor, a communal bath/shower facility on the first floor, and a second office in the basement. The garden at the front of the property is well maintained and has amble space for parking. The large garden at the rear is mainly lawn, although there is a new vegetable patch at the far end and a concrete patio area outside the second lounge. The home has developed clear information to help prospective service users and their representatives understand what specialist services can be provided. CMG currently charges £1,328.72 to £1,762.14 a week. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. From all the available evidence gathered during the inspection process the Commission for Social Care Inspection (CSCI) has judged the service as having significantly more strengths than areas of weakness. There are no significant areas for improvement relating to the health and safety of people using the service or issues of poor management. Key standards are generally met, but there are some areas of practice that need improving. Where weaknesses have been identified the Commission is confident the provider will manage them well. This unannounced site visit was carried out on a Friday between 10.00am and 3pm. During the course of this five hour inspection two people who currently live at Birdhurst Rise were spoken with at length; along with a visiting relative, the homes registered manager, and three other members of staff who were all on duty at the time. The two residents met were selected for ‘case tracking’. In addition to the feedback received from people met during the site visit the Commission also received 5 ‘have your say’ comment cards from service users relatives. The remainder of this site visit was spent examining the homes records and touring the premises. What the service does well: All the written and verbal feedback received from service users and their representatives about the standard of care provided at Birdhurst Rise was very complimentary. One service users relative wrote on a comment card, “I am always made to feel welcome when I visit the home and the staff generally appear to like the service users and speak to them with respect”. The Commission feels the home is particularly good at ensuring information about the services and facilities on offer are available in suitable formats that can be easily understood by the people who live at Birdhurst Rise, and their families. For example, the homes Statement of purpose/service users guide, new care and health plan formats, the providers complaints procedures, and safety notices are all available in a plain language format, which are frequently illustrated with ‘easy’ to understand pictures, symbols and photographs. This ensures information about how the home operates is made more meaningful and interesting for the people for whom the service is intended. All the people who use the service and some of their representatives commented very favourably about the kind and professional attitude of the staff team and all were very confident about their ability to deliver consistently good quality care. It was positively noted that the entire staff team have either already achieved a National Vocational Qualification in care or are currently working towards this objective. A lot of stakeholders met also expressed Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 6 satisfaction with the very open and inclusive leadership style of the registered manager, who comes across as a very personable and approachable individual. What has improved since the last inspection? What they could do better: All the positive comments made above notwithstanding there are some areas of weakness that need improving: People who use the service are given a choice about what they can eat and specific dietary needs are always well catered for. However, the homes manager conceded that more thought could be given to providing service users with better information about healthier eating. It is recommended that the providers seek advice from qualified dieticians about healthy eating and consider sending staff on nutrition training. A number of recording errors were noted on medication administration sheets sampled at random. The manager must remind her staff team to be more Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 7 diligent when handling medication and not to leave any gaps on medication administration sheets. The homes procedures for recruiting new staff are adequate, but will need to be improved to ensure the providers have access to all the information they require to make proper assessments about a candidate’s suitability to work with vulnerable adults. No written evidence could be located at the time of this site visit to show how many supervision sessions one member of staff selected at random had received since Christmas (2006). The manager told us that all her staff receive regular supervisions with suitably qualified senior members of staff, but conceded the homes approach to recording these sessions remained rather inconsistent. This issue was identified as a major shortfall at the homes last inspection. The time scale for the manager to take appropriate action has been extended for a second a final time and failure to address this on going matter will result in the Commission considering taking enforcement action to ensure future compliance. The service users continue to benefit from living in a well run home which a highly competent and experienced person manages. However, the manager has still not completed her NVQ level 4 training in both Management and Care and without this award she cannot be considered ‘suitably’ qualified to run a residential care home. 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. Birdhurst Rise, 7 DS0000066789.V339571.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 Birdhurst Rise, 7 DS0000066789.V339571.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): 1&2 Quality in this outcome area is good. This judgement has been made using all the available evidence. People who use this service have good information about the home in order to make an informed decision about whether the service is right for them. People’s needs are fully assessed prior to admission so the individual, their representatives, and the home can be sure the placement is appropriate. EVIDENCE: A copy of the homes latest Statement of Purpose and Guide was produced on request. The manager told us that the document was last reviewed in August and had been up dated accordingly to reflect any changes in provision. The document clearly sets out the objectives and philosophy of the service and what the people who use the service can expect in terms of the quality of the accommodation, qualifications of staff, and how to make a complaint. The Statement refers to providing services for an ‘all female gendered group’, which the manager told us is typing error. Furthermore, the age range specified in the document is too ridged and unwittingly identifies the ages of both the youngest and oldest people currently residing at the home. The manager told us that the homes Statement does not currently contain any Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 10 comments from the residents living at Birdhurst Rise, although the providers were in the process of ascertaining peoples views about the service they received as part of CMG’s new quality assurance monitoring system. Information about the home is available in ‘easy’ to understand formats, which are illustrated with all manner of colourful pictures, symbols, and photographs, thus ensuring they are more accessible to the people who live there. One service user spoken with told us they had been given a copy of the homes Guide, which they kept in their bedroom. The manager told us there had been one new admission since the homes last inspection and that she along with other members of the providers own assessment team had carried out a thorough assessment of the individuals care needs. Written admission documentation was adequate and included a copy of the individuals care management assessment. Basic information was available to staff to ensure they could meet the social, emotional and care needs of new service users. The manager confirmed that is was customary for all prospective service users to be asked about their religious beliefs and clearly understood the importance of ascertaining this type of information prior to admission. Birdhurst Rise, 7 DS0000066789.V339571.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 Quality in this outcome area is good. This judgement has been made using all the available evidence. Care plans reflect what is important to the individual, their capabilities, and what support they need to achieve their personal aspirations. The homes arrangements for assessing and managing risk are suitably robust to ensure service users are able to take ‘responsible’ risks and develop their independent living skills. EVIDENCE: The individual care plans for the two people selected for case tracking were both examined. Since the homes last inspection a new care plan format has been introduced. Where possible care plans are developed with the individual and their representatives. This more person centred approach places a greater emphasis on an individuals strengths and personal preferences. The plans celebrate an individuals life experiences and sets out clearly how all their current requirements and aspirations are to be met through positive Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 12 interventions. To help individuals to understand the information contained in their care plan the new format is illustrated with pictures and is written in plain language. One member of staff met told us the new care plan format was a better working tool that helped them deliver the support required by the people who used the service. This individual was also able to describe how they had helped develop the new care plans and accurately described the plans for the two service users whose care was being case tracked. This knowledge means that service users can be confident that they will get support from people who understand their care needs. The manager told us converting all the service users care plans into the new person centred formats was still a work in progress. One service user spoken with at length was very clear about their rights and also told us the home had helped set up an independent advocate for them. Assessments pulled from the two care plans being case tracked contained detailed guidance to help staff prevent and manage a number of significant risks associated with these individuals behaviours. There have been a number of unplanned absences from the home in the past 12 months and staff met demonstrated a good understanding of the homes recently revised missing persons policy and procedures. The person in charge of the early shift is commended for advising the inspector not to view a service users bedroom without appropriate staff support in accordance with a risk management strategy established for this individual. Risk assessments have been updated since the homes last inspection regarding unplanned absences and the Commissions database confirmed we were notified about these significant events without delay. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 13 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, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A good range of activities within the home and community mean the service users have various opportunities to participate in stimulating and motivating activities. The home has excellent arrangements in place to enable service users families to continue there involvement in their loved ones lives and are kept informed about all social, leisure and recreational activities they participate in. Dietary needs and preferences are in the main well catered providing daily variation, choice, and interest for the people who use the service, although more could be done to ensure service users are offered a healthier diet. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 14 EVIDENCE: During the course of this site visit one service user was observed making themselves a hot drink in the kitchen. The manager told us that several service users who are capable and willing are actively encouraged to make their own breakfasts. One service user spoken with at length said they prepare some of their own meals and enjoy cooking sausage and egg, which is their favourite. On arrival a couple of service users were observed getting into the homes people carrier with a member of staff. The manager told us they were going to a local day centre. Staff maintain an up to date record of all the activities service users choose to engage in both at home and in the wider community. The record revealed service users lead very active and fulfilling lives. The relative and friend of a service user who were visiting the home at the time of the inspection told us staff always made them feel extremely welcome and they were not aware of any restrictions on visiting times. One service user met said they could come and go as they pleased and would often take themselves off to the local shops or go and visit friends who lived locally. Written feedback received from three relatives was very complimentary about how the home. One relative wrote, “ The manager always telephones us to tell us how our ‘loved one’ is getting on and staff always accompany (our loved one) when they come to visit”. Another relative wrote, “ We are always invited to attend our loved ones reviews and Birthday celebrations”. During this visit a number of service users and staff from another CMG home in the vicinity arrived for a prearranged visit. The manager told us this was part of a new initiative for service users who lived in CMG homes that were relatively near to one another to spend more time together and get to know one another better. The manager also told us the home planned to develop a local newsletter for service users and their relatives to read and contribute too. Progress made on this excellent initiative will be assessed at the homes next inspection. One service user asked about meals said the food was ‘nice’. During lunch a member of staff was observed preparing spaghetti on toast for most of the service users, although there was an alternative meal of assorted meat sandwiches available for those who did not want a hot meal. Care plans contain detailed information about service users food and drink preferences, as well as their dislikes. Staff also maintain a detailed record of all the food the people who use the service actually eat at mealtimes, which showed people have a choice. However, the manager conceded that although the service users seem to enjoy their meals they do not always choose the healthier option and more could be done by staff to encourage healthier eating. The manager could consider a Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 15 number of different strategies such as seeking the advice of a dietician and/or having her staff team trained/instructed in how to prepare more nutritionally well balanced meals. In the past three months the homes record of food provided showed that none of the service users had been offered any far eastern influenced cuisine, despite this being identified as style of cooking one service user in particularly enjoyed. The manager told us she was aware of this shortfall and had already made arrangements for this individual to visit a local oriental food store to try and find out more about their food preferences. Progress made on this matter will be assessed at the homes next inspection. Birdhurst Rise, 7 DS0000066789.V339571.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has excellent arrangements in place to ensure the people who use the service receive personal support in the way they prefer and require, and that their unique physical and emotional health care needs are always recognised and met. The homes policies and procedures for handling medication need to be improved to ensure they are sufficiently robust to minimise the risk of service users being harmed and/or abused. EVIDENCE: All the service users met during this visit were suitably dressed in wellmaintained clothes that were appropriate for the season. One service user told us they always chose the clothes they wore each day. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 17 Since the homes last inspection new health care records have been developed that are stand-alone documents, which set out in detail a service users medical history and the outcome of all their appointments with various health care professionals. Like the new care plan format this single bound document is illustrated with all manner of pictures and is written in plain language to enable it to be better understood by both service users and staff. All the staff spoken with demonstrated an excellent understanding of each of the service users unique personal and health care needs, including both their emotional and physical requirements. The new booklet goes beyond what is expected of a provider and therefore exceeds National Minimum Standards for healthcare. During the course of this visit the senior in charge of the early shift told us they had already arranged a GP’s appointment for a service user who had just told her they felt unwell. Care plans inspected revealed that individuals who require support to promote their continence receive regular input from community-based nurses. Staff spoken with demonstrated a good understanding of individual service users continence management routines and the manager told us all the staff had recently received in-house training about promoting continue in a dignified and respectful manner. Staff maintain detailed records of all the accidents involving service users. There record showed that no accidents involving service users had occurred since the homes last Key inspection (Aug’06). Two recording errors were noted on medication administration sheets sampled at random, where staff had failed to enter the appropriate codes for medication not administered on a particular day. A similar recording error had been identified as part of an internal audit conducted by a member of the provider’s new quality assurance team. The manager must remind her staff team to be more diligent when handling medication and not to leave any gaps on medication administration sheets. All the medication held by the home on service users behalves is securely stored in a locked cabinet pinned to a wall in the laundry room. ‘As and when required’ medication protocols were made available on request, which set out in detail when and how staff should administer this type of medication. Birdhurst Rise, 7 DS0000066789.V339571.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The homes complaints and adult protection protocols and sufficiently robust and understood by staff to ensure service users feel safe and listened to. EVIDENCE: A copy of the homes complaints procedure was conspicuously displayed on a notice board in the hallway. The document was written in plain language and illustrated with colourful pictures to enable it to be read and understood by the people for whom it was intended. The manager told us to date she had never received any formal complaints about the homes operation, although more informal concerns are expressed by service users relatives from time to time. The manager told us she does not record these concerns or the action taken (if any) to resolve them. Two service users have been subject to a safeguarding adults referral in the past year. The manager demonstrated a good understanding of the local authorities vulnerable adult protection protocols following these two incidents and records showed that all the relevant agencies, which included the Commission, were notified without delay. As a result of an unplanned absence by a service user one night an alarm system has been installed that allows the holder of a pager to be discreetly notified that this individual’s bedroom door had been opened during the night. The manager told us that the service users care manager is in the process of Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 19 writing up this risk management strategy that allows the home to restrict this individual’s freedom of movement in this way. As a precautionary measure alarms have also been fitted to the homes patio doors at the rear of the property in both the kitchen and the second lounge. One service user said these alarms were quite ‘noisy’ when they were activated and it was disappointing to note that contrary to the homes policy the kitchen alarm had been left on during the day. The manager also told us that as the side gate in the rear garden and front door were both fitted with suitable locking devices it was not necessary to alarm both the back doors. The homes arrangements for securing the premises at night should be reviewed with all the relevant parties as soon as reasonably practicable. A second safeguarding referral regarding the homes arrangements for managing continence was not upheld following an initial enquiry into these allegations. Birdhurst Rise, 7 DS0000066789.V339571.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, 26, 27 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The excellent condition of the décor, fixtures, and fittings in this relatively new care home means the service users live in a very homely and comfortable environment. The homes arrangements for controlling infection are in the main sufficiently robust to ensure the service users also live in a very clean and safe environment. EVIDENCE: There have been no significant changes made to the interior design or décor of the home since it was last inspected. The manager told us that arrangements had been made for the banisters and skirting boards running along the length of the main stairs to be repainted. Progress on this matter will be assessed at the homes next inspection. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 21 The front garden has been vastly improved in the past few months with the planting of a wide range of flowers and shrubs that are now in bloom. The rear garden has also been improved with the creation of a vegetable patch, which one service user told us they were keen to grow things on. The rear garden has also been provided with a new shed and some additional garden furniture. One service user spoken with at length said they were very pleased with their new bedroom and liked the colour it was painted. Another service user told us they had enough space in their bedroom to store all their electrical home entertainment equipment. This individual also told us they were currently in negotiations with the manager to have satellite television installed in their bedroom. Daily records are appropriately maintained by staff of the temperature of hot water emanating from all the homes water outlets. The manager assured the inspector that all the homes shower facilities had been fitted with suitable thermostatic mixer valves that prevented water temperatures exceeding 43 degrees Celsius, in line with health and safety regulations. The home was clean throughout and no offensive odours were detected during a brief tour of the premises. The homes washing machine is capable of cleaning laundry at appropriate temperatures and has a sluice programme for dealing with foul laundry. The walls and floor of the laundry room are readily cleanable and a large Belfast sink for hand washing is prominently sited. Gloves and aprons were available in the laundry room for staff use and the manager told us the home has a contract for dealing with clinical waste, which is collected on a weekly basis. Yellow and black bags were also available for storing clinical waste outside before collection and staff met demonstrated a good understanding of the homes arrangements for disposing of this type of waste. During a tour of the laundry is was noted that a lidless wicker basket was being inappropriately used to dispose of used gloves, tissues ect. Birdhurst Rise, 7 DS0000066789.V339571.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, 33, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of suitably competent and experienced staff are employed on a daily basis to ensure the service users needs are met. Procedures for recruiting new staff are in the main robust, but will need to be improved to ensure the providers have access to all the information they require to make proper assessments about a candidate’s suitability to work with vulnerable adults. The homes arrangements for recording formal supervisions staff receive from suitably qualified senior members of staff remains inconsistent and will need to be improved if the service users are to benefit from being supported by well supervised staff team. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 23 EVIDENCE: The homes management team and all the other staff on duty at the time were observed interacting with the service users in a very patient and professional manner throughout the course of this inspection. One relative wrote on a comment card, “Staff empathise with the service users and seem very patient, caring, and kind”. Two service users asked about the team told us they got on well with staff and both knew who their designated keyworkers were. It was positively noted that in line with National Minimum Standards of training the homes entire staff team had either already achieved an NVQ level 2 or above in care or were currently studying for the equivalent by an agreed date. On arrival four support workers were all on duty. The manager confirmed that at least three staff are always on duty during the day with up to two additional staff employed to cover peaks periods of actively. The additional member of staff who was met during the inspection told us they were a bank worker who had been specifically employed that morning because she was a driver and would be able to take a number of service users to their day centres. This flexible approach to planning the duty rosters ensures that sufficient numbers of staff are always available to accompany service users on community-based activities. The manager told us that none of her current staff team could speak Japanese and therefore no one was able to communicate with a service user whose first language was not English. However, it was positively noted that the manager had held support worker interviews with a number of candidates who could speak Japanese. Progress made to employ a Japanese-speaking member of staff will be assessed at the homes next inspection. The home continues to experience relatively low rates of staff turnover and consequently the manager has only needed to recruit one new member of staff in the past 10 months. The new employees personal file was examined in some depth and found to contain the vast majority of information the service is legally obliged to carry out before allowing a person to commence working at the care home. This included two written references, of which one had been supplied by the individuals most recent employer; up to date Criminal Records Bureau and Protection of Vulnerable Adult checks, proof of their identify; and a completed induction record. The individual’s file did not contain a completed job application form, which the manager told us was probably still being held at the provider’s central head office. There is an induction programme that ensures new staff members are given the right information to be able to do their jobs well. Individualised training plans are in place for each member of staff that not only identifies what skills people have, but also what their training needs are. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 24 Staff spoken with were very clear about their roles as support workers, knew what was expected of them, and showed a good understanding of the actions they needed to take to meet and promote equality and diversity. Documentary evidence was produced on request in the way of certificates of attendance that showed sufficient numbers of the current staff team had received mandatory training in a fire safety, first aid, food hygiene, health and safety, dignified management of conflict, adult protection/abuse, handling medication, and promoting continence. The manager told us that dates have been arranged for her staff team to attend moving and handling, and infection control courses. Progress on these matters will be assessed at the homes next inspection. The homes most recent recruit told us they had received a number of formal supervision sessions with a suitably qualified senior member of staff since commencing work at the home. However, no written evidence could be located at the time of this site visit to show how many supervision sessions another member of staff selected at random had received since Christmas (2006). The manager told us that the three members of staff selected at random had all received three supervisions since the beginning of the year, but conceded the homes approach to recording these sessions remained rather inconsistent and ad hoc. This issue was identified as a major shortfall at the homes last inspection. The time scale for the manager to take appropriate action has been extended for a second a final time and failure to address the on going matter will result in the Commission considering taking enforcement action to ensure compliance. Birdhurst Rise, 7 DS0000066789.V339571.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from living in a reasonably well run home which a highly competent and experienced person manages. However, the manager has still not completed her NVQ level 4 in both Management and Care which she will need to do to be considered suitably qualified to run a residential care home. The new quality monitoring systems introduced by the providers appear to be sufficiently robust to ensure service users and their representative’s views about the standard of care provided will underpin the homes development. In the main sufficiently robust health and safety arrangements are in place to ensure the welfare of service users, their guests, and staff are promoted and protected. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 26 EVIDENCE: The homes registered manager still does not have the required NVQ level 4 training in either management or care. She told us due to problems beyond the provider’s control no arrangements are currently in place for her to enrol on a suitable NVQ course in the near future. Nonetheless, it was clear from feedback received from service users, their relatives, and staff that all the major stakeholders appreciate the manager’s very open and inclusive style of leadership. The manager was able to describe a clear vision of the home and able to evidence a sound understanding and application of ‘best practice’, particularly in relation to continuous improvement and customer satisfaction. The manager was able to evidence her commitment to promoting equality and diversity in the home and meeting service users individual needs. In the past year the manager has reviewed her training in infection control, dignified management of conflict, medication, and adult protection, as well as attend the providers new managing finances and budgets course. The manager demonstrated a good understanding of the new limits placed on CMG home managers regarding the spending of service users monies without appropriate authorisation. The new quality monitoring systems the providers have introduced appear to be extremely comprehensive covering every aspects of life in the home. The new quarterly inspections and the subsequent reports produced by members of the providers own quality assurance team are extremely thorough and exceed the Commissions expectations regarding how frequent internal audits should be carried out. The manager told us that she believes the results of any stakeholder satisfaction surveys the home undertakes will be published by the end of the year for any interested parties to view. Progress on this matter will be assessed at the homes next inspection. Fire records revealed that the homes fire alarm system continues to be tested on a weekly basis. Fire drills involving all the service users and staff on duty at the time are undertaken on a monthly basis, although the manager is considering reducing the frequency to once a quarter once the homes most recent admission has familiarised themselves with the home fire evacuation procedure. During a tour of the premises it was noted that none of the homes fire resistant doors were being inappropriately wedged open to prevent there automatic closure in the event of a fire. Up to date Certificates of worthiness were in place to show that suitably qualified engineers had checked all the homes gas (Landlords) and electrical installations, portable electrical appliances, water heating for legionella, and fire extinguishers, in the past twelve months. Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 27 Birdhurst Rise, 7 DS0000066789.V339571.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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 2 X 2 X 4 X X 3 X Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 29 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 YA1 Regulation 4(1)(c), Sch 1.5 Requirement Timescale for action 01/07/07 2. YA20 13(2) & 18(1) 3. YA30 13(3) 4. YA34 19, Sch 2.6 The homes Statement of purpose must include the correct sex of the people for whom the service is intended to ensure people have sufficient information when choosing the care home. No gaps must be left on 01/06/07 medication administration sheets and staff must be reminded about their duty of care to appropriately maintain these records. All waste created in the 02/06/07 home that could possibly spread infection must be deposed of appropriately in lidded in pedal bins. Copies of job application 15/06/07 forms completed by new members of staff must be available for inspection on request to enable the manager to assess peoples suitability for the post of support worker. Version 5.2 Page 30 Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc 5. YA36 17(2), Sch 4.6(f) & 18(2) 6. YA37 9(2)(b)(i) Records of all the formal supervision sessions a person working at the home has with a suitably qualified member of staff must be made available for inspection on request. Previous timescale for action of 1st February 2007 not met. The individual responsible for the day-to-day operation of the home must be at least working towards achieving an NVQ Level 4 in both Management and Care by an agreed date. Previous timescale for action of 1st March 2007 not met. 01/07/07 01/09/07 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 YA1 Good Practice Recommendations The homes Statement of purpose should be revised to include stakeholder’s views about the quality of the care provided. Also, information about people’s ages should reflect the range the home intends to accommodate and not the actual age range of the people currently residing at Birdhurst Rise. The home should be more proactive when it comes to encouraging service users to eat healthier meals and should give serious consideration to seeking the advice of dietician about this matter, as well as consider instructing staff about preparing more nutritionally balanced meals. All informal concerns raised about the homes operation should be recorded and the action taken (if any) in response. Arrangements for alarming the homes back doors at night should be reviewed with all the relevant professionals. 2. YA17 3. 4. YA22 YA23 Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Birdhurst Rise, 7 DS0000066789.V339571.R01.S.doc Version 5.2 Page 32 - 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. 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