Inspection on 03/07/08 for Birdhurst Rise, 7

This inspection was carried out on 3rd July 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birdhurst Rise, 7 15/01/08

Birdhurst Rise, 7 01/06/07

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 27/09/2008.

CARE HOME ADULTS 18-65 Birdhurst Rise, 7 7 Birdhurst Rise South Croydon Surrey CR2 7EG Lead Inspector Lee Willis Unannounced Inspection 3rd July 2008 10:15 Birdhurst Rise, 7 DS0000066789.V365563.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.V365563.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.V365563.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 020 8681 2216 020 8688 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 Ltd Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: 2. Learning disability - Code LD The maximum number of service users who can be accommodated is: 8 15th January 2008 Date of last inspection Brief Description of the Service: Birdhurst Rise is a large detached property offering accommodation and personal support for up to eight generally ‘middle aged’ adults with learning disabilities and behaviours that may challenge the service. Vivian Okeke was appointed the homes acting manager in October 2007 and her application for the Commission to consider her ‘suitability’ for the post is currently being processed. The service has its own transport and is within ten minutes of walk of several main line bus routes and a local train station. South Croydon is also within easy walking distance that has a wide variety of community facilities and services, including local shops, cafes, restaurants, pubs, and banks. The property comprises of eight single occupancy bedrooms all with en-suite toilet and bathing/shower facilities. Communal areas are largely located on the ground floor and include a main lounge, separate dinning area, large open plan kitchen, a top floor visitor’s room, spacious entrance hall/lobby, laundry room, and two office spaces located on the ground floor and basement. There are sufficient numbers of communal bathroom and toilets located throughout the house. The large garden at the rear is well maintained. The home has developed clear information to help people who use the service and their representatives to understand what facilities and services are provided. CMG currently charges from £1,328.72 to £1,762.14 a week. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use the sevice experience good quality outcomes. This marks a significant improvement on its previous zero star rating. From all the available evidence we gathered during this key inspection it was clear the service now has significantly more strengths than areas of weakness. Furthermore, where areas for improvement have emerged in the recent past the service has been particularly good at recognising this and establishing action plans to address any identified shortfalls. We spent four and a half hours at the home. During the visit we met all seven of the people who currently live there, the acting manager, the new regional operations manager for the home, a financial auditor representing the providers quality assurance team, and four support workers. We also looked at records, documents, and photographs, including the care plans for two people who were chosen to have their cases tracked. The remainder of this site visit was spent touring the premises. We received two ‘have your say’ comment cards about the home. One was completed by a person who uses the service and the other by a member of staff. As part of the inspection process the acting manager also completed and returned an Annual Quality Assurance Assessment (AQAA) to tell us about this service, how it makes sure of good outcomes for the people using it, and any future developments that are being planned. What the service does well: All the written and verbal comments we received from the people who live at the home was very positive. Typical comments included, “I like it here”, and “there’s always something to do”. All the staff on duty during this site visit, including the acting manager, were observed actively supporting people who use the service to make more informed choices about what activities they engaged in, and more generally were seen encouraging everyone (so far as practical) do a lot more things for themselves. E.g. a member of staff was overheard offering a service user a choice of activities they might wish to participate in that morning, whilst the manager was seen encouraging another individual to dress themselves using various verbal prompts and cues. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 6 The living environment of this relatively new service remains very homely, comfortable, and clean. The layout of the home, especially the open plan kitchen and rear garden, also provides the people who live there with a lot of space to either enjoy communal activities together or relax in private. It was evident from comments made by a number of the people who use the service that they are encouraged to see the home as their own. We saw that staff relate well with the people who live at Birdhurst Rise and the atmosphere remained relaxed and pleasant throughout the course of the visit. Typical comments made by people who live there about staff included, “staff are nice”, “the manager listens to me”, and “my keyworker takes me out a lot”. What has improved since the last inspection? The relatively new acting manager has a clear vision about the direction she wants to take the home in and has made a number of significant improvements to the home in the past six months. All the requirements identified in the home’s last inspection report have also been addressed in a timely fashion. See details below: The homes medication handling practices have significantly improved in the last six months. Staff now maintain clearer records of all medicines administered in the home, far more detailed protocols for the use of ‘as required’ (PRN) medication have been established, all staff ‘authorised’ to handle medication on behalf of the people who live at Birdhurst Rise have up dated their medication training, and all medicines stored in the home are now correctly labelled and administered in accordance with their prescribed instructions. All staff have recently up dated their safeguarding training in order that they have the necessary knowledge and skills to recognise, prevent, and report abuse. Staff are now receiving formal supervision sessions on a regular basis with suitably qualified senior staff and appropriate records of the outcome of these meetings are now being kept. Finally, the homes fire safety arrangements have been improved to ensure all staff who regularly do nights participate in at least one fire drill every three months and the fire risk assessment for the building is reviewed on a regular basis and up dated accordingly to reflect any changes in provision. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 7 The service has also improved in a number of other key areas of practice. Arrangements for reviewing risk management strategies that are in place to minimise the likelihood of people who use the service being harmed has significantly improved in recent months. This is now done on a more regular basis and risk assessments are up dated accordingly to reflect any changes in need and/or circumstances. We agree with the comments made by the acting manager in the summary section of its Annual Quality Assurance Assessment that the service now provides “a more stimulating environment for the people who use the service to live in terms of the variety of opportunities they now have to engage in more meaningful activities both at home and in the wider community.” During a tour of the premises it was noted that a new flat screen television, karaoke machine, DVD player, exercise bike, and a large outdoor trampoline had all recently been purchased to enhance the social lives of the people who use the service. The introduction of monthly sessions between people who use the service and their designated keyworker has given people more opportunities to make more informed decisions about how they live their life’s and to influence the running of their home. The acting manager has also introduced a staff delegation record, which staff meet told us had proofed very useful when planning what needed to be done each shift. Input from a qualified dietician has ensured the menus the people who use the service help plan each week include far healthier eating options for them to choose between. What they could do better: All the positive comments made above notwithstanding their remains a number of areas of practice where further improvement is required in order to enhance the lives of the people who use the service: The acting manager who is very competent still needs to achieve her Registered Managers Award in order to be considered suitably qualified to run a residential care home for adults with learning disabilities. All staff who are involved in assessing the suitability of new referrals should receive training in how to implement the providers relatively new compatibility tool for new admissions. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 8 The home should also be more proactive when it comes to encouraging and actively supporting people who wish to take far greater control of their medication to do so. This will promote peoples right to choose and do develop their independent living skills. The practice of alarming certain bedrooms and the patio doors should be reviewed with all the relevant parties to ensure peoples freedom of movement and dignity is not restricted unnecessarily. The home has experienced unusually high levels of staff turnover in the past year and has consequently left the service with a large number of staff vacancies. However, with four new people currently being recruited some progress has been made to address this staffing crisis, although the acting manager concedes the home is still a long way off having a full compliment of staff. The acting manager also told us she would be mindful when recruiting new staff of the imbalance that currently exists between her almost entirely black British and Afro-Caribbean staff team and the homes mainly white British service user group. Finally, the service should consider establishing a time specific action plan setting out how it intends to ensure 100 of its staff team hold an NVQ in care. This will ensure the home continues to drive improvement and the people who use the service are supported by suitably qualified staff. 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.V365563.R01.S.doc Version 5.2 Page 9 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.V365563.R01.S.doc Version 5.2 Page 10 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 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 for them. EVIDENCE: The acting manager told us the homes Statement of Purpose and Guide was last reviewed in April 2008 and up dated accordingly to reflect all the changes that had occurred in the home in the past 12 months, including the erroneous statement that the home was just for female service users. Staff confirmed that the service still has one vacancy, but has not received any new referrals in the past 6 months. An issue regarding the compatibility with others already living in the home has been a problem for Birdhurst Rise in the past. The acting manager who was the homes former deputy told us she was fully aware of the problems caused by getting the mix of the people who live at Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 11 the home wrong and was determined to ensure this risk was minimised at the referral stage. The acting manager told us she has still not received any training in respect of CMG’s new compatibility assessment tool, although she believed arrangements were in place for this to happen by August 2008. Progress made to achieve this gap in training will be assessed at the homes next inspection. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 12 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 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. 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, managing and reviewing identified risks have improved since the service was last inspected. This ensures the people who use it are kept safe, while their rights to choose and take responsible risks are not restricted unnecessarily. EVIDENCE: We looked at the care plans for the two people we had selected to track their cases. Both plans were person centred and set out in great detail how their current personal, social, and health care needs were to be meet, what support through positive interventions they required, and what their strengths and wishes were. Both plans had been reviewed in the past six months involving all Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 13 the relevant people and are up dated accordingly to reflect any changes in provision. We agree with comments made by the acting manager in the homes AQAA that monthly keyworking sessions is one area of practice that has improved since the homes last inspection. Records of these monthly sessions held between people who use the service and their designated keyworkers were contained in the two care plans being case tracked. Topics covered in last month’s sessions included social activities engaged in, health appointments attended, and what these individuals hoped to achieve next month. One staff told us they found the relatively new tool a useful way of keeping up to date with the changing needs and aspirations of the people they keyworked. One person who uses the service told us staff always help them make decisions about what they wear, eat, and do each day. A member of staff was observed politely offering someone who was colouring in some pictures in the dinning room whether they would like to continue what they were currently doing or join in a ball game in the garden with their fellow peers. In the past year we were concerned risk management strategies were not being reviewed at frequent enough intervals and up dated accordingly to reflect peoples changing needs and/or circumstances. As required in the homes last inspection report the acting manager has now improved the way risk assessments and management plans are reviewed and updated. Recently reviewed and up dated risk assessments and corresponding risk management strategies were contained in both the care plans being case tracked. It was also noted that detailed guidelines to help staff prevent and effectively manage behaviours that challenged the service had also been recently reviewed and up dated accordingly in respect of the two individuals whose care was being case tracked. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The opportunities the people who use the service to maintain and development their independent living skills and participate in the day to day running of their home has significantly improved since the last inspection. Furthermore, the number and variety of social, leisure and recreational activities the people who use the service have the opportunity to participate in has also significantly improved since the last site visit, although there remains scope to continue improving links with the local community. Dietary needs and preferences are well catered ensuring the people who use the service are provided with daily variation, choice, and far more nutritionally well-balanced meals that meets people specific food preferences. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 15 EVIDENCE: It was positively noted on arrival that the vast majority of the people who use the service were actively engaged in various ball games in the back garden, which were being organised by a member of staff. All the people participating in the game appeared to be enjoying themselves. As previously mentioned in this report we observed a member of staff offering an individual who uses the service a choice of what social activities they could participate in that morning. The acting manager told us two other people who use the service had already gone out with staff, one for a walk and the other to attend a health care appointment. One person spoken with at length about activities on offer to them at the home told us they did “lots of drawing and had recently started going to the gym”. Entries made in the homes relatively new activities book and the daily diary notes for the two people whose care was being tracked showed that significant progress had been made by the home to ensure service users had far more varied and meaningful activities to choose to participate in each day, especially within the home. Since the last inspection the acting manager has arranged for an aroma-therapist to visit the home on a regular basis and introduced ‘beautify make-over’ sessions for everyone. It was also noted during a tour of the premises that a new flat screen television, karaoke machine, DVD player, exercise bike and large trampoline had recently been purchased by the home to enhance the social lives of the people who use the service. It was evident from the comments made by several people who use the service that the wide variety of games and art materials conspicuously displayed throughout the home that they are well used. Furthermore, photographic and written evidence viewed during this visit also revealed that more was being done to enable people who use the service to engage in more interesting community based activities such as visiting local parks, going to the gym, and attending a number of local social clubs in the evenings. We concur with the acting managers comments contained in the summary section of the AQAA that significant progress has been made to provide the people who use the service with more stimulating social lives, although further work is required to “source more outside activities”. One survey completed by a person who uses the service told us “staff help them clean, and do mopping”. One person who uses the service told us staff had helped them clean and tidy their bedroom that morning. This task could be identified on a weekly domestic chores chart, which was conspicuously displayed in the dining room and in peoples care plans. All the verbal feedback received and records viewed regarding peoples participation in domestic chores around their home indicated that the relatively new acting amanger was Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 16 committed to ensuring everyone who lives at Birdhurst Rise was actively encouraged and supported to develop and or maintain their independent living skills. Typical comments made by a couple of people who use the service about the meals provided included, “I like the sausages”, and “the food is nice”. As recommended in the homes last inspection report the acting manager has sought the advice of a qualified dietician who has helped staff device new four weekly menus that balances the food preferences of the people who use the service with healthier eating options. For example, the manager told us that to accommodate an individual’s preference for cheese with almost every meal a decision was with the individual concerned to buy more low fat cheeses. The acting manager also told us that staff now regularly arrange for one person who uses the service to go out for a Chinese meal to ensure this particular individuals cultural heritage and preference for oriental style cuisine is catered for. One person who uses the service told us they had eaten “egg and baked beans for their lunch”, which they had chosen from that days menu. The new menus are conspicuously displayed on a notice board in the kitchen and are illustrated with all manner of pictures to ensure the people who use the service have every opportunity to choose what they eat at mealtimes. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Suitably robust arrangements are 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 continually recognised and met. Policies and procedures for handling medication are in the main sufficiently robust to keep the people who use the service safe, although far more could be done to actively encourage and support people who wish to take greater responsibility for administering their own medication to do so within an appropriate framework of risk. EVIDENCE: All seven of the people who currently live at the home were suitably dressed in well-maintained clothes that were appropriate for the time of year. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 18 Relatively new health care action plans are in place for all the people who live at the home. These records set out in detail the dates and the outcomes of all the health care appointments everyone had attended in the past 6 months. Records for the two people who care was being case racked showed they had visited their GP, dentists, and chiropodists. During the visit staff were observed supporting one individual to get ready to go out and attend a hospital appointment. The acting manager told us only one significant accident involving a person who uses the service had occurred in the last six months which had resulted in them sustaining a minor head injury. Records indicate that staff on duty appropriately dealt with the incident at the time and that we were notified without delay about their subsequent admission to accident and emergency. No recording errors were noted on any of the medication administration records (MAR) sheets currently in use at the home. These records accurately reflected current stocks of medication held in the home on behalf of the People who use the service, including all as required PRN medication. All medicines were securely stored in a locked metal cabinet attached to a wall in the laundry room. A pharmacist representing a primary health care trust recently visited the service and identified no major shortfalls regarding the homes medication handling practices. The good practice recommendation made in the homes previous report that the views of the people who use the service about the possibility of them taking greater responsibility for administering their own medication within an appropriate framework of risk has not been carried out as suggested. We strongly recommend the acting manager assesses peoples willingness and capacity to take far greater control of their own medication, however limited this might be, in order to enable people who use the service to develop their independent living skills in line with the homes stated aims and objectives. All the requirements made by the Commissions specialist pharmacy inspector, Vashti Maharaj, during her last visit to the home have been met in full. The acting manager was able to produce evidence on request to show improvements have been made to the homes arrangements for receiving medicines into the home, information regarding the appropriate use of sedatives (PRN) medicines, medication record keeping, and staff medication handling training. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes arrangements for dealing with concerns and complaints are sufficiently robust and understood by staff to ensure people who use the service feel listened too and safe. In the main the homes arrangements for ensuring the people who use the service are protected and kept safe are sufficiently robust. EVIDENCE: The acting manager told us no complaints have been made about the homes operation since it was last inspected. One person who uses the service told us “they could talk to staff if they were unhappy”. The acting manager demonstrated a good understanding of what constituted a ‘significant’ incident and was able to name all the external agencies that would need to be notified without delay about the occurrence of such events. Records revealed that ten incidents had occurred in the home in the last six months, which were all appropriately dealt with by staff on duty at the time. Having crossed referenced this information with our own database we were also able to confirm these incidents had all been reported to us in a timely fashion, which marked a significant improvement in the homes reporting practices over the past year. The acting manager told us she had learnt some important lessons from mistakes made by her predecessor regarding the reporting of Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 20 significant incidents to external agencies, such as the CSCI and the relevant funding authorities. In the last six months there has been one allegation of abuse made within the home, which the acting manager promptly reported to all the relevant authorities, including Croydon Councils safeguarding team and the Commission. The allegation was made after a person who resides at the home went missing without authorisation. The matter was investigated under the local authorities safeguarding protocols and the allegation of neglect by an unnamed member of staff who had left the garden side gate open was up held. The side gate was securely locked on arrival and during a subsequent tour of the grounds. The acting manager was able to produce documentary evidence on request that showed risk management strategies and suitable checks had been reviewed and up dated accordingly to minimise the likelihood of a similar incident reoccurring in the future. The acting manager told us that all five of the homes permanent staff team have recently up dated their safeguarding adults and CMG’s own British Institute of Learning Disability approved managing challenging behaviour training. One member of staff confirmed that had recently attended refreshers courses in both safeguarding and managing challenging behaviour. During a tour of the premises it was noted that three bedrooms and both the patio doors at the rear of the property are all alarmed. Following a number of incidents at the home in 2007 we are aware what the rational was originally behind the fitting of these alarm systems, but feel these arrangements are now overdue a review in light of recent changes within the home. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 21 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, 28 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The interior decoration of the home, including its fixtures, and fittings, are well maintained ensuring the people who use the service live in a very homely and comfortable environment. The homes arrangements for controlling infection are sufficiently robust to ensure the people who use the service also live in a very clean and safe environment. EVIDENCE: Since the last inspection there have been no significant changes made to the interior design and decoration of the home, although as recommended in the last report some new furniture had recently been bought for the garden. The acting manager told us she was in the process of arranging for carpets in communal areas of to be cleaned and for the stairwell banister to be repainted. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 22 Progress made on these matters will be assessed at the homes next inspection. A number of people who use the service told us they “liked the way Birdhurst Rise looked and particular liked the large garden at the rear”. One bedroom was viewed with the occupant’s permission who told us they had enough space to keep all their things and liked their bedroom a lot. The bedroom appeared to be well furnished and quite personalised with various pictures and photographs hung on the walls. During a tour of the premises it was noted that all the communal areas were spotlessly clean. Records are appropriately maintained of regular checks carried out by staff on hot water emanating from the homes baths. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 23 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 & 36 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have safe and appropriate support as there are enough competent, qualified staff on duty at all times. People’s needs are also met because staff get the right training, supervision and support they need from the management team to carry out their duties effectively. EVIDENCE: Two support workers on duty at the time of this site visit were observed interacting with a number of the people who currently use the service in a very caring and respectful manner. Typical comments made by one person who use the service included, “I like most of the staff who work here”, and “I know which staff I can speak to if I’m unhappy”. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 24 In the past year the service has experienced unusually high levels of staff turnover, which has meant a far greater reliance on temporary agency and bank staff. However, the new acting manager told us that so far as reasonable practicable she tried to use a relatively small number of temporary staff who had become familiar with the needs of he people who use the service and the homes daily routines. The manager also told us that two of these temporary workers had recently been appointed full-time permanent members of staff. The acting manager told us that although she had not employed any new staff since the last inspection she was nonetheless in the process of appointing four new members of staff, including a new deputy manager. The majority of these new staff will be transferring from within CMG and most have already worked at Birdhurst Rise as bank staff. The home still has three staff vacancies, which the manager told us she is very keen to fill as soon as practicable. Progress made by the service to achieve a full compliment of staff will be assessed at its next inspection. The new manager told us she believed the recruitment of good quality carers was the cornerstone of delivering good outcomes for the people who use the service and was very keen to ensure the right people for the job are employed. Since the homes last inspection the acting manager has introduced staff delegation records that he feels has helped staff have a better understanding of their roles and responsibilities. Five staff including the acting manager were on duty throughout the course of this inspection which was sufficient to meet the personal, social and health care needs and wishes of all the people who currently reside at Birdhurst Rise. It was also noted that the age range and gender mix of the staff team reflected that of the service users, although in terms of ethnicity there was clearly an imbalance between the two groups. (I.e. the current staff team largely consists of individuals from black British or Afro-Caribbean backgrounds, whilst the majority of the service users are white British). The manager told us she was acutely aware that the racial and cultural backgrounds of the vast majority of her staff team was very different from that of the service users and would be mindful of this imbalance when recruiting new staff. Staff training records revealed that the majority of the homes current staff team had either achieved a National Vocational Qualification Level 2 or above in care or were enrolled on suitable courses in line with National Minimum Standards. However, with so many staff vacancies the good practice recommendation made in the homes previous report that the providers establish a time specific action plan setting out how it proposes to ensure 100 of its existing and new workforce are NVQ trained is repeated here as a means of ensuring quality. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 25 Since the homes last inspection the new acting manager has reassessed all her staff teams training strengths and needs. Staff files sampled at random all contained documentary evidence of the training they had each recently undertaken, which included fire safety, first aid, basic food hygiene, and safeguarding adults. It was positively noted that as identified in a number of the homes previous reports supervision of staff and records kept of the outcome of these sessions were now being appropriately maintained by the manager. In line with the providers own supervision procedures staff records showed that all he homes current members had each received at least three formal supervision sessions with a suitably trained senior member of staff during the first half of 2008. One member off staff told us “they found the sessions very useful and a good way of getting the training you needed arranged”. The acting manager told us each member of staff should have their performance and training achievements and needs formally appraised at least once a year, a process she has now started. Minutes of staff meetings revealed they were now being held on a monthly basis. These meetings were all well attended and had covered a wide variety of relevant topics, including safeguarding, health care appointments, record keeping, health and safety, quality assurance, requirements identified in CSCI reports, and staff training/supervision issues. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 26 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service have confidence in the care home because a suitably competent manager now runs it. Sufficiently robust quality assurance and monitoring systems are in place that allows the views of the people who use the service to influence homes operation and development. The welfare of people who use the service and staff are promoted and protected because all the homes fire and health and safety arrangements that are in place are sufficiently robust to keep people safe. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 27 EVIDENCE: The relatively new acting manager has worked for CMG for seven years in various capacities, including as a senior support worker and deputy manager. In addition, Vivien has now been in operational day-to-day control of Birdhurst Rise since October 2007. The acting manager was able to demonstrate she has the knowledge and skills to run a residential care service for adults with learning disabilities and has a clear vision for the service. Vivian is a qualified mental health nurse (RNM) and told us she expects to have completed her NVQ level 4 (Registered Manages Award) training in management by November 2008. Vivien is aware that her appointment is subject to a ‘fit’ person interview with the Commission and she was able to confirm during this site visit that she has recently submitted her registered managers application form for processing. Progress made on both these matters will be assessed at the homes next inspection. The acting manager told us she had received a lot of support from her new regional manager who was carrying out an unannounced regulation 26 visit of the home on my arrival. It was evident from issues identified in the homes two previous Regulation 26 reports that the acting manager is committed to ensuring action is always taken in a timely fashion to resolve any issues identified in Regulation 26 reports. A member of the provider’s quality assurance team was also carrying out an unannounced audit of the homes finances during this inspection. The new manager told us she was familiar with CMG’s new financial checks and balances procedures and had recently received training (February 2008) in how to manage a care homes budget and look after services users monies safely. In addition to regular financial spot checks carried out by senior representatives of CMG the manager also told us she is responsible for carrying out weekly audits of service users monies. The manager was able to produce a fire risk assessment for the building, which she had up dated in February 2008 to reflect current provision. Fire records revealed that the homes fire alarm system continues to be tested on a weekly basis and that fire drills are now being carried out once a quarter. Records of the homes last two fire drills showed that all the homes staff, including permanent night workers, had all been involved in at least one drill in the past six months in line with the London Fire and Emergency Planning Authorities good fire safety guidelines. As required in the homes last report a suitable sound activated release mechanism has now been fitted to a fire resistant bedroom door to accommodate the wishes of the current occupant who likes to have their door a jar. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 28 Up to date Certificate of worthiness were made available on request to show that suitably qualified engineers had checked the homes gas installations, water heating systems (legionella), fire extinguishers, and portable electrical appliances in the past twelve months. During a tour of the kitchen it was noted that all items of food kept there were correctly stored in line with basic food hygiene, including items taken out of their original packaging, which were correctly labelled and dated. Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 29 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 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 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 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 30 No 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 YA37 Regulation 9(2)(b)(i) Requirement The homes relatively new acting manager who is responsible for its day-to-day operation must be suitably qualified and hold the equivalent of an NVQ Level 4 in both Management and Care. Timescale for action 01/01/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA2 Good Practice Recommendations All staff, including the manager, who will be expected to use CMG’s new compatibility assessment, should be trained in its use. This will ensure all the people who use the service are kept safe. People using the service should be able to manage their own medication if they wish in order to promote their choice and independence providing all the risks associated with the activity are thoroughly assessed and managed. This recommendation was made at the homes last inspection, but the acting manager has yet to DS0000066789.V365563.R01.S.doc Version 5.2 Page 31 2. YA20 Birdhurst Rise, 7 3. YA23 consider carrying it out. The practice of alarming certain bedroom and patio doors should be reviewed as a matter of urgency with all the relevant parties, including people who use the service, their relatives and care managers. This will ensure peoples freedom of movement and dignity is not restricted unnecessarily. The way in which the service recruits new members of staff should be reviewed to ensure the ethnic and cultural mix of the staff team is far more representative of that of the people who use the service. The service should consider establishing a time specific action plan setting out how it intends to ensure 100 of its staff team hold an NVQ in care. This will ensure the home continues to drive improvement and the people who use the service are supported by suitably qualified staff. This recommendation was made at the homes last inspection, but has not been implemented. 4. YA34 5. YA32 Birdhurst Rise, 7 DS0000066789.V365563.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. 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