Inspection on 04/08/06 for Birdhurst Rise, 7

This inspection was carried out on 4th August 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 15 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 01/06/07

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 4th August 2006 09:30 Birdhurst Rise, 7 DS0000066789.V306402.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.V306402.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.V306402.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.V306402.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Not applicable Brief Description of the Service: 7 Birdhurst Rise is owned and managed by CMG a specialist provider of residential care for adults with learning disabilities and challenging behaviour. The service is registered with the CSCI to provide accommodation and personal support for up to eight younger adults of either gender. Sarah Brown successfully underwent a ‘fit’ person interview with the Commission to become the homes registered manager and has been in operational day-to-day control since the service opened in March 2006. This detached Victorian property is situated in a quiet residential suburb in South 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 with excellent links to central Croydon and the surrounding areas. A variety of local shops, cafes, and pubs are also within easy walking distance. The property comprises of eight single occupancy bedrooms, all of which have en-suite facilities; a main lounge; separate dinning area/smoking room; a large open plan kitchen with a second dinning area; a laundry room; two offices; and a gym/music room in the basement. There is one communal bath/shower on the first floor. The garden at the rear of the property is mainly lawn, but there is a small patio area for service users to sit. The home ensures prospective service users and their reprensentatives are supplied with all the information they need to know about the services and facilities provided and how much they will be charged for them. Birdhurst Rise, 7 DS0000066789.V306402.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 the Commission for Social Care Inspection (CSCI) considers this newly registered service to have substantially more strengths than weaknesses, although there are also some important areas that need improving. The Commission is confident the providers will acknowledge all the weaknesses identified in this report and will manage them well. This unannounced site visit was carried out on Friday 4th August 2006 between 9.30am and 3.00pm, which was followed up two days later on the afternoon of Monday 7th August. These two visits combined latest a total of eight hours. During the course of these site visits all six of the service users currently residing at the home were met, of whom three were spoken with at length. The homes relatively new Registered, Regional Operations, and Deputy managers, were also spoken with, along with four support workers, of whom one was informally interviewed. Finally, a service users relative, who was visiting there loved one at the time, was also met, albeit briefly. None of the Commissions comment cards sent out to service users, their relatives, and other representatives have been returned since the home has been open. The remainder of these site visits was spent examining the homes records and touring the premises. What the service does well: All verbal comments received from service users and their relatives about this new home were in the main extremely favourable about the standard of care being provided. All three service users spoken with at length said they felt the best thing about living at Birdhurst Rise was the quality of the meals and staffs attitude. One service user explained that ‘staff were always available when you needed them and were good listeners’. The atmosphere in the home throughout the course of this eight hour inspection felt extremely relaxed and homely, and the interior décor of this recently converted Victorian town house had been carried out to a good standard. It was positively noted that in accordance with recommended good practice and CMG’s own admissions procedures the needs and personal goals of all the new service users had been thoroughly assessed prior to anyone moving in and everyone’s care plans had been reviewed within their first three months of residency to determine whether or not each placement was working. These reviews had all been well attended by service users, their new keyworkers, the homes manager, and where applicable the individuals next of kin, external advocate, and Care manager. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 & 5 Quality in this outcome area is adequate. This judgement has been made using all the available evidence. Prospective service users and their representatives have all the information they need to make an informed choice about whether or not to move in, although the homes Guide is still not available in a suitable format to enable service users to access all the information they and their representatives require. Sufficiently robust arrangements are in place to ensure prospective service users unique aspirations and needs are thoroughly assessed prior to admission to determine whether or not the service is capable of meeting them. Service users/their representatives are not currently supplied with standardised forms of contract that set out their individual terms and conditions of occupancy. Consequently, they do not have access to up to date information about the services and facilities provided or how much they can expect to be charged for there use. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 9 EVIDENCE: The manager stated that all seven of the referrals that have been accepted since the home opened have all been supplied with the services new Statement of Purpose and Residents Guide. However, the original documents that were sent out were eventually recalled because the homes new management team did not think the format was particularly accessible to the people for whom the service was intended. These documents are currently being amended to make them far more ‘service user friendly’ and it was agreed that copies of the new version would be supplied to each service user, their representatives, and the Commission. Two service users spoken with at length both said they would like to have a copy of the homes Guide to keep in their bedrooms. The home has received around 25 referrals since it opened, of which seven were eventually accepted. All these service users personal files were examined in some depth and found to contain all the information required by the Standards, including separate needs assessments undertaken by both the homes manager and Care managers representing the relevant placing/funding Authorities. These assessments covered every aspect of the service users unique personal, social, and health care needs and the information was clearly used to generate each service users care plan. Two out of the seven referrals accepted had been emergency placements and it was evident from information contained in their care plans that a thorough assessment of their needs had also been carried out by the manager within a week of their arrival. The new manager was able to demonstrate a good understanding of the homes admissions criteria by refusing to accept approximately three-quarters of all the new referrals made mainly on the grounds that the individual would not be compatible with the existing service user group. However, the manager conceded that in light of the speed at which one placement had broken down the referral should not have been accepted in the first instance as the home was clearly not capable of meeting this individuals identified needs. Two service users meet said they had both been invited to visit the home before deciding whether or not to move in. One service user said they had chosen the bedroom they were to eventually occupy and had been invited to stay over night during their second introductory visit. The manager said that due to administrative delays at head office none of the service users, some of whom who had resided at the home for almost six months, had still not been supplied with written and costed contracts setting out their terms and conditions of occupancy. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using all the available evidence. The home develops and agrees with each service user an individual care plan, which are constantly reviewed to reflect changing needs and personal goals. Sufficiently robust arrangements are in place to ensure service users are being appropriately supported to take responsible risks as part of a structured programme to promote independent living skills, whilst the hazards associated with these activities are, so far as reasonably practicable, minimised. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 11 EVIDENCE: Each service user has been supplied with a care plan that was based on information gathered from their needs assessments, which includes a recent photograph, address of next of kin, and date of admission. Two care plans sampled at random both contained documentary evidence to show these plans had both been reviewed and up dated accordingly twice within the first six months of these individuals arrival. These reviews had been well attended by the relevant service users, their new keyworkers, the homes manager, and where applicable the individuals next of kin, independent advocate and Care manager. A service user spoken with at length said they had attended their last care plan review meeting along with their new keyworker. Furthermore, it was positively noted that one service user who is subject to the Care programme Approach to care planning had a third three monthly review with their Community Psychiatric Nurse, in addition to their six weekly and biannual care plan review meetings. One service user spoken with at length said they had a longstanding independent advocate who continued to play a very active role in their lives. The manager said she planned to ascertain whether or not other service users might wish to be represented by independent advocacy services. Progress made on this matter will be assessed at the homes next inspection. The home has notified the Commission without delay about the unplanned absences of two service users in the past four months, in accordance with the Care Homes Regulations (2001). The details of these significant incidents were all recorded and the relevant care plans up dated accordingly to reflect this newly identified risk, which included risk management strategies to be followed by staff to minimise the likelihood of similar incidents reoccurring in the future. A keypad device has subsequently been fitted to the front door. The one service user who travels independently in the wider community without the need for staff support said they were happy to ask staff to open the front door for them as and when required, although the deputy manager has agreed to consult the individual about the possibility of them being given access to the keypads access code. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using all the available evidence. The social, leisure and recreational opportunities service users have the chance to engage in, both at home and in the wider community, are well managed and provide daily variety and stimulation. Suitable arrangements are in place to enable service users to maintain good links with their families and friends, and daily routines ensure service users rights’ and responsibilities are recognised and respected as a means of promoting independence. Service users unique dietary preferences appear to be well catered for, although records are not being kept in sufficient detail to enable anyone inspecting them to determine whether or not diets are nutritionally well balanced and varied. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 13 EVIDENCE: Two service users met said although they were not particularly religious they were confident that staff would support them to attend places of worship of their choosing. The manager said one service user is regularly offered the opportunity to attend Sunday services at a local church, but has declined to do so on most occasions in recent months. This spiritual need is recorded in the individuals care plan and the manager was adamant that staff would continue to offer this person the chance to go to church each month. According to three daily diary notes sampled at random these service users appear to lead very active lives and have the chance to pursue all manner of social and educational interests of their choice, both at home and in the wider community. Throughout the course of this site visit it was observed that all bar one of the service users, who seemed quite content to sit in the communal lounge and watch music videos, were either already out or were preparing to go out with staff to attend various activities in the local community. One service user said they were going out to pick up their bike, while another said they planned to go swimming with relatives. The manager said the rest of the service users had either gone out for a walk or a drive with staff. The home has an open visitors policy and one service users relative spoken with at the time of this unannounced site visit said staff always made them feel extremely welcome and they were not aware of any restrictions on visiting times. The manager said there is an expectation that service users should be actively encouraged and supported to participate in domestic chores around the house. One service user was observed being supported by a member of staff to vacuum the lounge. The one service user who smokes was fully aware that they were only permitted to do so in the dinning room providing food was not being served. The manager agreed that service users views about this arrangement would need to be ascertained and an alternative place for people to smoke considered. Progress on this matter will be assessed at the homes next inspection. All five service users asked about the quality and choice of the meals provided said it was ‘excellent’. The deputy manager said mealtimes are very flexible and one service user who had got up later than everyone else was observed helping themselves to some cereal from a kitchen cupboard. The kitchen door remained locked at all times during both site visits. It was positively noted that a another service user was asked by the member of staff preparing their lunch what filling they would like in their sandwich. As the only service user who was eating at the time the atmosphere in the open plan kitchen/dinning room was extremely relaxed and congenial. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 14 The deputy manager said service users are always asked several hours in advance what meals they would like to prepare each evening from the stocks of food held in the kitchen at the time. The deputy conceded that the homes arrangements for ensuring service users are actively involved in choosing the food they eat remains rather informal and a more structured process of menu planning needs to be developed with appropriate records kept. It was positively noted during a tour of the kitchen staff were observed actively supporting one service user to bake a cake. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is adequate. This judgement has been made using all the available evidence. On the whole the home has sufficiently robust arrangements in place to ensure the health care needs of the service users are recognised and met, although its procedures for keeping the Commission informed about the occurrence of all significant incidents need to be tightened up to ensure how the home deals with such events continues to be open and transparent. Sufficiently robust systems are in place to ensure medication records are appropriately maintained and monitored to protect service users. EVIDENCE: On arrival all the service users who were at home were appropriately dressed in light well-maintained summer clothes. The one service user who had chosen to get up late was politely prompted by staff to have a shower and get dressed as they were scheduled to go out later. Records of all the service users appointments with health care professionals are appropriately maintained by staff and one service user said staff always would them to any hospital appointment they might have. The homes accident Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 16 book revealed that none of the service users had sustained any injuries or been admitted to casualty since the home had been opened. The manager confirmed that four significant incidents involving service users had occurred since the home had been open, the majority of which pertained to unplanned absences that the Commission was notified without delay. However, the CSCI’s Database shows that the home failed in its duty of care to notify the Commission about the occurrence of an extremely serious incident involving a service user whilst out in the community who is no longer residing at the home as a direct result. Records are kept of all medicines received and administered in the home and no recording errors were noted on the four Medication Administration sheets sampled at random. These records accurately reflected the current medication stocks held by the home on service users behalves, which are securely locked away in a metal cabinet fixed to the wall in the ground floor office. It was noted that there was insufficient space between the cabinet and ground floor office doors which both collided when opened simultaneously. Both the homes Regional Operations and registered managers agreed that a more suitable location for the medicines cabinet needed to be found. Protocols for the use of all ‘as required’ (PRN) medication handled on service users behalves were available on request along with separate registers that staff used to record the receipt, administration and disposal of PRN medication. These registers are counter signed by two appropriately trained members of staff each time any PRN medication is handled. It is recommended this good practice measure be extended to incorporate all Controlled Drugs handled in the home as well. It was positively noted that in accordance with current good practice all Controlled Drugs being held in the home are securely locked away in a separate metal box kept within the homes medicines cabinet. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is adequate. This judgement has been made using all the available. The home has sufficiently robust arrangements in place to ensure service users have access to an effective complaints procedure and, so far as reasonably practicable, are protected from harm, abuse and neglect. EVIDENCE: The homes complaints procedure is available in an easy to understand format that is illustrated with all manner of symbols, pictures, and photographs to make it far more accessible for the people for whom the service is intended. A copy of the procedure is conspicuously displayed in the ground floor corridor and makes it clear who will deal with complaints and how long you could reasonably expect to receive a response. Two service users spoken with at length said staff always listened to their point of view and they both very felt confident that if they were concerned or worried about anything they could speak to their keyworker or the manager about it. The homes new complaints log revealed that no formal complaints or informal concerns had been made about the homes operation since opening. The home has a copy of the Local Authorities vulnerable adult protection protocols and CMG’s own procedures regarding adult protection and abuse, which has recently been reviewed, is explicit about passing on any concerns staff may have abut suspected or actual abuse to external agencies, such as the police, Croydons vulnerable adult protection team, and the CSCI. The manager said there had not been any allegations of abuse made within the home since it was opened and was very clear about her reporting Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 18 responsibilities in respect of disclosures of abuse. A support worker who was informally interviewed said they had read the whistle blowing policy and was very clear who they needed to speak to if they suspected or witnessed service users being abused, and what actually constituted abuse. The same member of staff also said recognising, prevention and reporting abuse was covered as part of their induction. It was clear from care plans sampled at random that several service users had been assessed as having behaviours that could ‘challenge’ the home at times. It was therefore positively noted that two care plans examined in depth both contained specific guidance to help staff deescalate any potentially ‘hazardous’ incidents. The deputy manager who had attended CMG’s own British Learning Disability (BILD) approved managing conflict training (DigMan – Dignified management of conflict) was very clear that physical intervention techniques should only be used as a ‘last resort’ when all other de-escalation strategies had failed to defuse a potentially ‘challenging’ incident. The deputy confirmed that no incidents of physical restraint had been used in the home since it opened. Staff files sampled at random revealed that not everyone had received or up dated their existing managing challenging behaviour and vulnerable adult protection training. A least one certificate of attendance revealed several members of staff who had transferred from other CMG homes needed to refresh their adult protection/physical intervention training. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28 & 30 Quality in this outcome area is good. This judgement has been made using all the available evidence, including a site visit to this service. The physical layout and interior décor of this new service had been carried out to a good standard ensuring the service users live in a safe, bright and comfortable environment that suits their needs and rights. EVIDENCE: This new home was very clean and free from any offensive odours on arrival. Several service users met said the home is always kept clean and tidy. The new furnishings and fittings in the home are all of good quality, domestic in appearance, and meet fire safety regulations. A fire safety officer from the London Fire and Emergency Planning Authority visited the home before it opened and all the recommendations made in the subsequent report were met in full. The manager is aware that the front door bell is damaged and needs repairing. One service user gave their permission to view their bedroom, which had recently been decorated to a good standard. The service user said they had been provided with all the furniture they required and their was sufficient Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 20 space for them to store all their personal belongings. The service user said they particularly liked having their own en-suite shower. The radiator in the bedroom had been covered and a space provided to ensure the heating system could still be individually controlled as and when required. To other bedrooms were viewed at random which were also newly decorated and furnished to a good standard. These bedrooms also looked extremely personalised and seemed to reflect the individual occupants taste. The deputy confirmed that all eight bedrooms are single occupancy and have been provided with en-suite shower/or bathing facilities. The temperature of hot water emanating from the homes only communal bath on the first floor was found to be a safe 43 degrees Celsius at 16.00 on the second day of the inspection. Two shower outlets tested in service users bedrooms at the same time were also found to be operating at safe levels. The deputy manager was aware that hot water temperatures used in showers and baths must never exceed 43 degree Celsius and was adamant that all these outlets had been appropriately fitted with preset thermostatic mixer valves, which included all the wash hand basins in service users bedrooms. The homes new open plan kitchen is suitably equipped and spacious. The kitchen seems to be a focal point where service users and staff like to congregate other than just at meal times. The large garden at the rear of the property is mainly laid to lawn, although there is a patio area with some furniture for service users, their visitors and staff to sit on. The manager agrees that the rear garden needs landscaping and plans to plant some more trees, as well as start a vegetable patch, which a couple of service users spoken with said they were keen to be involved with. The homes new washing machine is capable of washing clothes at appropriate temperatures and also has a sluice facility. The laundry room has handwashing facilities and is far enough away from the kitchen and dinning room so that there is no need for food to be stored, prepared, or eaten in the vicinity. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 & 36 Quality in this outcome area is adequate. This judgement has been made using all the available evidence. On the whole service users benefit from clarity of staff roles and responsibilities, although the homes arrangements for ensuring all new staff, including existing members who have transferred from other CMG homes, receive a structured induction and a copy of the General Social Care Councils code of conduct need to be improved. Furthermore, although sufficient numbers of suitably competent and qualified staff are employed on a daily basis to ensure the individual needs of the service users are being met, more staff need to receive further training in a number of key areas of practice, including basic food hygiene, managing challenging behaviour, and supervising colleagues. The homes arrangements for recruiting new members of staff are sufficiently robust to protect the service users from avoidable harm and the service users also benefit from being supported by a well-supervised staff team. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 22 EVIDENCE: All the service users spoken with said they got on well with all the staff who always treated them well. The manager and other staff were always observed taking their time to politely deal with service users requests throughout the course of this inspection. The one member of staff informally interviewed said they had not been provided with a copy of the General Social Care Councils code of conduct, although they had been given a job description and the terms and conditions of their employment. The manager confirmed that none of her new staff team who had been recruited from outside CMG would have received these booklets. On arrival four members of staff were on duty, including the deputy manager, whose numbers were adequate to meet the assessed needs of the six service users currently residing at the home. The hours being worked by staff on duty at the time of this visit matched those recorded on that morning’s duty roster. The deputy said a minimum of three supports were always on duty throughout the day, although this would increase to four as soon as the homes two service user vacancies were filled. At night two waking staff are employed. The manager is supernumerary to these calculations, but said she tries to work at least one ‘hands on’ shift each week to monitor her new staff teams performance. The manager also said she and her deputy have a very flexible approach to planning the duty rosters and will often employ a fourth member of staff to work at ‘peak’ periods of activity in order to meet service users lifestyles. Last months duty rosters revealed that each member of staff had at least two full days off each week. Ten new support workers have been recruited since the home was opened. The deputy said the home remains five support workers short of its full staff compliment, although interviews are currently being held to address this shortfall. In the interim CMG’s large pool of Bank workers are being used to cover any gaps in staffing. All ten new members of staff’s personal files, including the deputy managers, were examined in depth. Each file contained at least two written references, of which one always came from the individual’s last employer; copies of Passports as proof of identity, and (where applicable) Home Office approved work visas. The deputy manager was fully aware that the number of hours any person working on an overseas Student visa was limited to no more than twenty hours each week during term time. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 23 Staff files inspected revealed that only those members who had been recruited from outside CMG had been checked against the Protection of Vulnerable Adults register. The four members of staff who had transferred from other CMG homes had used their old CRB checks originally obtained when they first joined the company. As most of these CRB checks were now over three years and therefore carried out prior to the introduction of the Protection Of Vulnerable Adults register in July 2004, these internal transfers represented a missed opportunity for the providers to undertake far more rigorous checks of their employees. It was noted that only the deputy manager was allowed to commence working at the home on just a POVA First check while awaiting his full CRB disclosure to be processed. The deputy was very clear that during this period he remained office based, did not provide any personal care and was supervised at all times by a suitably competent member of staff when interacting with service users. The deputy manager said the home was using the Leaning Disability Awareness Framework, which all new staff had to complete as part of their induction. Furthermore, all new staff were expected to complete a three-day orientation course as part of their initial induction training, which a member of staff interviewed said had covered safe working practices. It was therefore surprising to note from records sampled at random that despite assurances from the deputy manager that all staff had completed their induction, only new staff who had not previously worked for CMG had appropriately maintained records kept on file of this training. The personal files for all those staff who had transferred from other CMG homes only contained old induction checklists that had initially been completed when these particular individuals had first joined CMG. These old induction records only demonstrated these member of staffs understanding of the service they had recently transferred from and are clearly not portable. It was evident from certificates of attendance sampled at random that sufficient numbers had recently received training in fire safety, first aid, and handling medication in a residential care setting. However, five staff files sampled at random revealed that insufficient numbers had received or refreshed their basic food hygiene and CMG’s own Dignified Management of conflict training. Furthermore, the deputy confirmed that excluding the registered manager, he was the only other member of staff who had been awarded a National Vocational Qualification in care level 2 or above, although three other members were now enrolled on an approved NVQ course. The Deputy was fully aware that the deadline for at least 50 of the homes support workers to have achieved this award had expired at the end of 2005 and said he had recently enrolled on an NVQ assessors course in order to rectify this training shortfall. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 24 With so many new members of staff as well as gaps in their training identified at this inaugural inspection, it is strongly recommended the management give serious consideration to carry out a comprehensive needs assessment of the relatively new staff teams strengths and weaknesses. The homes staff team is ethnically and culturally very diverse and is reasonably reflective of the area, although the manager conceded that the team was not particularly representative of the service users backgrounds, the majority of whom were white British. The manager is mindful of this ethnic and cultural imbalance and will take this into account when recruiting new staff. It was positively noted that the personal files of five new members of staff inspected at random all contained documentary evidence to show they had each received at least two formal supervision sessions with their line manager during their probationary periods of employment. The deputy manager confirmed that three senior members of staff, which includes himself, the homes manager and another senior are all responsible for supervising their colleagues. The deputy manager conceded that although he has a lot of experience supervising colleagues he has not received any formal training in respect of this task. Birdhurst Rise, 7 DS0000066789.V306402.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using all the available evidence. The service users benefit from living in a reasonably well run home which is managed by a suitably experienced manager who is in the process of achieving her NVQ level 4 in both Management and Care. In the main sufficiently robust arrangements are in place to ensure the health, safety and welfare of service users, their guests and staff are protected, although the frequency at which the homes fire alarm system is tested must be improved as a matter of urgency. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 26 EVIDENCE: The newly registered manager has over two years experience working in a senior management capacity with adults with learning disability and behaviours that challenge. The manager has not achieved a National Vocational Qualification Level 4 in Management and Care, although she is enrolled on an approved course, which she plans to have completed by the end of the year (2006). The manager said she receives a great deal of support and advice from her Regional Operations Manager (line manager) who carries out the provider’s unannounced monthly inspections of the home. Minutes of service user and staff meetings held in the home since it opened revealed they are both being held at regular intervals. Several service users met said they enjoyed attending these meetings where they could express their points of view about the way the home was being run. Topics discussed at the last service user meeting included activities and day trips. Two staff meetings have been held in the past five months, which were also well attended and covered all manner of topics, including staff training and service users individual needs and wishes. The providers have created Equal opportunities and racial harassment/bullying policies that are reviewed at regular intervals and refer to all the relevant antidiscrimination legislation, (e.g. Race Relations, Sex, and Disability Discriminations Acts). The manager confirmed that the home has a professionally recognised quality assurance system in place, which will be used to ascertain the views of service users and their representatives. The manager was fully aware that the results of any quality assurance surveys undertaken by the providers should be published within the first year of the homes operation (i.e. by April 2007). Progress made on this matter, along with the results of the provider’s own unannounced inspections, will be assessed at the homes next inspection. The deputy manager said a fire risk assessment of the building had been carried out before the service opened, but a copy was not available on request because it was still being written up at Head Office. Records of the homes fire alarm test revealed that this had been correctly carried out by staff on a weekly basis up until May 2006, but for some unknown reason was now being carried out on a monthly basis. Fire drills are being carried out on a monthly basis to ensure all the new service users and staff have the opportunity to participate in a fire practice. The deputy confirmed this would be reduced to a quarterly basis when the service user group and staff team have stabilised. Three fire doors released at random on the ground floor all closed flush into their frames during a tour of the premises. Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 27 Up to date Certificates of worthiness were available on request as proof that suitably qualified engineers had tested the homes gas installations, electrical systems, fire extinguishers and alarm system, and water temperatures for legionella before the home had opened. All items of food found in the fridge were correctly stored and fridge/freezer temperatures recorded at regular intervals in line with environmental health standards. Birdhurst Rise, 7 DS0000066789.V306402.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 2 2 3 3 X 4 3 5 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 2 32 2 33 3 34 3 35 2 36 2 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 3 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 3 2 X X 1 X Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 29 Not applicable 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(2) & 5(2) Requirement A revised copy of the homes Statement of Purpose and Service users Guide must be supplied to each of the service users and the Commission. Each service user and their representatives must be supplied with a standard form of contract that sets out their terms and conditions of occupancy in respect of facilities and services to be provided, including the amount and method of payment of fees to be charged. Records of the meals being chosen by service users must be kept up to date to enable anyone authorised to inspect them to determine whether or not service users diets are satisfactory and their food preferences are being taken into account when planning menus. Timescale for action 01/10/06 2. YA5 5(1)(b) (c) 01/10/06 3. YA17 12(3) & 17(2), Sch 4. 13 01/09/06 Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 30 4. YA19 37(1)(e) 5. YA20 6. YA23 7. YA23 8. YA31 9. YA32 10. YA35 The home shall give notice to the Commission without delay of the occurrence of any event, which adversely affects the well being of any service user. 13(2) & 23(2)(l) A far more suitable location must be found for the homes medication cabinet to minimise the risk of staff injuring themselves or making mistakes whilst handling service users medicines. 13(6), 18(1) & All members of staff must be 19, Sch 2.4 suitably trained to recognise, prevent, and report vulnerable adult abuse, in accordance with the providers and the Local Authorities vulnerable adult protection protocols. Documentary evidence of receipt of this training must be kept in the home. 13(6), 18(1) & All members of staff must be 19, Sch 2.4 suitably trained to manage challenging behaviour. Documentary evidence of receipt of this training must be kept in the home. 18(4) All new members of staff must be provided with a copy of the General Social Care Councils codes of conduct and good practice. 18(1) & 19, Sch At least 50 of the homes 2.4 support workers must have achieved an NVQ Level 2 or above or be enrolled on a suitable course. 17(2), Sch All staff, including existing 4.6(f) & 18(1) members who have transferred from other CMG homes, must receive a structured induction and records of this training appropriately maintained. DS0000066789.V306402.R01.S.doc 15/08/06 01/11/06 01/12/06 01/12/06 01/09/06 01/01/07 01/09/06 Birdhurst Rise, 7 Version 5.2 Page 31 11. YA35 18(1) & 19, Sch 2.4 12. YA36 13. YA37 14. YA42 15. YA42 All staff must be suitably trained in basic food hygiene. Documentary evidence of this training must be made available on request. 18(2) & 19, Sch All senior staff authorised to 2.4 formally supervise their colleague’s on a regular basis must be suitably trained to perform this task. 9(2)(b)(i) The individual responsible for the day-to-day operation of the home must have achieved an NVQ Level 4 in both Management and Care, or hold an equivalent qualification. 23(4) Fire risk assessments of the building must be carried out and any significant findings recorded. This document must be kept in the home and made available for inspection on request. 17(2), Sch 4.14 The homes fire alarm & system must be tested on a 23(4)(c)(iv) (v) weekly basis and appropriate records kept, including any action taken to remedy defects. 01/12/06 01/12/06 01/03/07 01/09/06 15/08/06 Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 32 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 YA7 Good Practice Recommendations Staff should ascertain which service users wish to procure the services of an independent advocacy and help them find out about advocacy services in the local area. Service users who are capable of travelling in the wider community without staff support should be consulted about whether or not they would like to have access to the homes new keypad device. Service users views about allowing the dinning room to be used, as a smoking area when food is not being served should be ascertained and alternative arrangements considered if necessary. The good practice of maintaining a separate PRN medicines register should be extended for the use of all Controlled Drugs held by the home on service users behalves. The rear garden should be landscaped and suitably adapted to meet service users wishes. The providers should consider renewing checks on all staff whose CRB’s are over three years old and check all staff against the relatively new POVA register when they transfer within CMG. The manager should be mindful of the cultural and ethnic imbalance that currently exists between her staff team and the service users when she next recruits new members. A training needs assessment should be carried on the homes entire staff team to identify any gaps in their knowledge and skills and appropriate action taken to rectify these shortfalls. 2. YA9 3. YA16 4. YA20 5. 6. YA28 YA34 7. YA33 8. YA35 Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Birdhurst Rise, 7 DS0000066789.V306402.R01.S.doc Version 5.2 Page 34 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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