Inspection on 05/08/08 for Birwood

This inspection was carried out on 5th August 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Birwood 19/08/09

Birwood 19/04/07

Birwood 23/02/06

Birwood 11/08/05

Birwood 21/01/05

Birwood 15/04/04

Birwood 04/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 13/03/2009.

CARE HOME ADULTS 18-65 Birwood Wheathills Road Huyton Knowsley Merseyside L36 5UR Lead Inspector Daniel Hamilton Unannounced Inspection 5th August 2008 10:00 Birwood DS0000021516.V360218.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 Birwood DS0000021516.V360218.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. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Birwood Address Wheathills Road Huyton Knowsley Merseyside L36 5UR 0151-449-3758 0151 449 3758 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.c-i-c.co.uk. Community Integrated Care Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category/ies of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD The maximum number of service users who can be accommodated is: 3 Date of last inspection 19th April 2007 Brief Description of the Service: Birwood is a three bed-roomed bungalow that is situated in Wheathills Road, Huyton and is close to local amenities. The service is provided by Community Integrated Care and is registered to provide personal care and support to three younger adults with a learning disability. The home does not currently have a Manager in post that is registered with the Commission for Social Care Inspection. There is one acting manager and a team of staff that support the people who live in the bungalow. The property has three bedrooms, a lounge, kitchen / dining area and a small spare room that is used as an office by the staff. Overall, the property is decorated and furnished to a satisfactory standard and provides a homely environment that is domestic in character. There are gardens to the front and rear of the property however these are maintained to a very basic standard and some areas are unkempt and in need of maintenance. Care Home Fees range from £1,132.08 per week. Birwood DS0000021516.V360218.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 1 star. This means the people who use this service experience adequate quality outcomes. This unannounced inspection took place over one day and lasted approximately 8 hours. Three people were living in the home at the time of the visit. A partial tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Acting Manager and a support worker were spoken with during the visit. Likewise, the three people who were living in the home were encouraged to participate in the inspection process using their preferred methods of communication. Survey forms were also distributed to each of the people using the service and a number of staff prior to the inspection, in order to obtain additional views and feedback about the service provided. All the key standards were assessed and progress / action taken in response to the previous requirement and recommendations from the last key inspection in April 2007 was reviewed. What the service does well: What has improved since the last inspection? Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 6 Since the last visit, the property had been fitted with a new kitchen, floor covering and a cooker, as the previous kitchen was in need of refurbishment. What they could do better: A Statement of Purpose had been developed, which provided information on Birwood. The Acting Manager was advised to update the document to ensure all the criteria identified in Schedule 1 of The Care Homes Regulations 2001 is included. The pictures, signs and symbols used in the document, should also be reviewed to ensure they are more reflective of the subject area. This will enable prospective residents to make an informed decision on the service and to understand the information more easily. Likewise, the menu plan for Birwood should be updated and a record of the dietary intake for each resident maintained. This will help to provide evidence that the people using the service receive a healthy and nutritious diet. Support / Essential Lifestyle plans viewed were in need of review or additional information. All care plans must be kept up-to-date and under review to demonstrate that the needs of the people using the service are monitored and appropriately planned for. Assessments of need should also be kept under review to ensure the needs of the people using the service are monitored. Examination of records revealed that the people using the service had limited opportunities to participate in leisure and community based activities. The range and frequency of community-based activities should therefore be developed and expanded, to enhance the quality of life for the people using the service. The arrangements for the management of residents’ finances / expenditure must improve further, in order to protect the financial interests of vulnerable adults. All transactions must be open, transparent and in agreement with each resident and / or their representative. A copy of the local authority’s safeguarding adults procedure should also be obtained for staff to reference. This will help staff to fully understand the local arrangements for safeguarding vulnerable people. At the time of the visit, each resident did not have an up-to-date Health Action Plan and records were not available to confirm that some of the people using the service had accessed routine dental and optical appointments. The health and welfare of the people using the service must be promoted and effectively planned for, to ensure the health care needs of residents is safeguarded. An audit trail for medication received into Birwood was not available as there was no record of the date medication was received, quantity and / or details of the person receiving medication into the home. This information should be recorded to ensure best practice. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 7 Since the last visit, a new Acting Manager had taken over responsibility for Birwood. It was not possible to verify that the Acting Manager had been appropriately recruited as recruitment records were not available for inspection. Records relating to the Acting Manager must be retained in Birwood, to provide evidence that all staff have been correctly recruited. At the time of the visit, the staff training records were not up-to-date and this caused difficulties in assessing the training needs of the staff team. An up-todate record of all training undertaken must be maintained in Birwood and action should be taken to ensure all outstanding staff complete safe working practice and other key training relevant to their role. This will help to provide evidence that the people using the service are supported by trained and competent staff. The maintenance of the grounds and the front ramp should be reviewed, to ensure the people living in the home benefit from safe, attractive and accessible gardens / facilities. Furthermore, arrangements should be made to ensure the fire alarm system is tested every week to protect the health and safety of the people using the service. A service certificate should also be obtained, to confirm the Fire Extinguishers have been serviced and risk assessments should be kept under review to ensure potential / actual hazards are identified and controlled. The Acting Manager should submit an application to the Commission for Social Care Inspection, to register as the Manager of the service as a matter of priority. This will ensure the service operates in accordance with the requirements of the Care Standards Act 2000. Furthermore, the Acting Manager should familiarise himself with the Quality Assurance Process operated by Community Integrated Care (Registered Provider). This will help to provide evidence that the service is run in accordance with best practice. 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. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies and procedures are in place to ensure the needs of prospective residents are assessed prior to moving into the home. Information on the service is in need of review, to enable prospective residents to make an informed decision on the service. EVIDENCE: A Statement of Purpose had been produced for the prospective and current residents using pictures, signs and symbols. The acting manager was recommended to update the document as there was no information on the: number of staff working at the home; admission criteria; arrangements for social activities, hobbies, religious observance, leisure interests and consultation with service users / relatives and the number and size of rooms in the home. Furthermore, full details of the complaints procedure was needed. Advice was also given to review the pictures, signs and symbols used in the document, so that they were more reflective of the subject area. It was acknowledged that the current people living in the home may not benefit from this information - but this should be considered for prospective residents. As identified at previous inspections, standard 2 is a key standard to be assessed in the home. This could not be assessed as no new residents had Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 10 moved into Birwood since the last visit. Records showed that the three people living in the home had been in residence for a number of years and the acting manager reported that the original assessments for the three residents using the service had been archived and an up-to-date assessment of need was not in place for each person living in the home. The Annual Quality Assurance Assessment (AQAA) for the service and previous inspection records confirmed that Community Integrated Care (Registered Provider) had developed policies and procedures in relation to referral and assessment. The acting manager confirmed the needs of prospective residents be fully assessed, before any agreement would be made for a person to move into Birwood. Contracts from the Landlord and the Registered Provider were available for inspection, which had been developed in a standard format. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of care planning and personal finances is in need of ongoing development and review in order to promote rights, independence, wellbeing and choice. EVIDENCE: The personal files of the three people living in the home were viewed during the visit. Each file contained a range of documentation including Care / Support and Essential Lifestyle Plans. Care / Support plans viewed had generally been completed to a satisfactory standard and outlined; the needs of the people using the service, objectives and staff instructions. All the three plans were in need of review at the time of the visit. Furthermore, Essential Lifestyle Plans (ELP) viewed were in need of additional information as the information was limited and some key sections had not been completed. One example viewed had not been dated and two were in a draft format. Advice was given to the Acting Manager on how to develop the care planning process. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 12 The Acting Manager and support worker on duty demonstrated a satisfactory awareness of the principles of good care practice and the support needs of the people living in the home, despite the absence of some key information and the residents having little verbal communication. The opportunity for the residents to make decisions and their needs known relies to some extent on the staff team understanding and responding to their non-verbal communications. The people using the service were observed to be relaxed and comfortable in their home environment and were seen to respond positively to staff interaction by smiling, touching, gestures and / or responsive sounds. Discussion with staff confirmed the residents were encouraged to take appropriate risks associated with the normal aspects of daily life and staff were available at all times to offer support. A range of environmental and personcentred risk assessments had been developed to safeguard the welfare of the people using the service, however all were in need of review. Examination of financial expenditure records revealed that the arrangements for withdrawing large sums of money from service user’s accounts for purchases remained in need of review, as there were two occasions when the representatives of the people using the service had been written to - seeking approval for large withdrawals after money had been withdrawn or spent from the residents’ accounts. The acting manager reported that one of the relatives had given verbal approval prior to the transaction being made however this had not been recorded. This practice must stop. The rights of the people using the service must be promoted and protected to safeguard vulnerable people from financial abuse. Furthermore, procedures for managing each resident’s money must be clear, open and transparent. Similar issues were also highlighted at the previous inspection. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The lifestyle experienced by the people using the service is restricted as there are limited opportunities for people to participate in leisure and community-based activities. EVIDENCE: The people living at Birwood did not attend day services for people with a learning disability. Community Integrated Care (Registered Provider) provided staffing 24 hours per day. Discussion with staff and examination of daily report records revealed that the people using the service had received limited opportunities to access their local communities and had not received an annual holiday since 2006. Records highlighted that the main community-based activity was shopping for personal items or food. The Acting Manager reported that only two of the people using the service had regular contact with family. Records of contact had been appropriately Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 14 recorded and provided evidence that relatives were invited to participate in personal planning processes. Discussion with staff and / or examination of records confirmed the people using the service were assisted by staff to prepare meals, go shopping for household products and to buy food. The Acting Manager reported that staff provided varying levels of assistance to residents with eating and drinking and confirmed that specialist advice would be obtained from a dietician and / or speech and language therapist if necessary. Food was purchased for the home via a petty cash account. At the time of the visit the service had £92.30 allocated for food and £13.46 for cleaning equipment each week. A four-week menu plan had been developed. The menu plan did not identify alternative choices and was vague as a number of meals did not indicate what vegetables were being served. Furthermore, it was not possible to determine the dietary intake of each resident, as records had not been maintained. Staff were observed to have a good rapport with residents and were observed to assist people in making various choices. A communication book had been developed to assist a resident to exercise choice and control over his life and residents’ likes, dislikes and choices were respected. Birwood DS0000021516.V360218.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. 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 available evidence including a visit to this service. The management of healthcare and associated records is in need of review, in order to safeguard the welfare of the people using the service. EVIDENCE: The people living at Birwood required assistance with all aspects of personal care and support. The Registered Provider (Community Integrated Care) had developed a range of care plan documentation for staff to record information on the personal and health care support needs of the people using the service. Although some of this important information was either incomplete, missing or in need of review, staff spoken with were able to demonstrate an awareness of the needs, preferences and preferred routines of the people using the service. Furthermore, staff were observed to offer support to service users in a personcentred and dignified manner. Examination of health care records revealed that none of the three residents had an up-to-date health action plan. Although records of contact with general practitioners, district nurses, chiropodists, hospital consultants and / or physiotherapists were available, summary records of health care appointments Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 16 detailed that two people had no record of dental appointments and had not visited opticians since 2003. Likewise, one resident had no record of dental appointments from May 2002 to January 2008 and had required major dental work during February 2008. The Annual Quality Assurance Assessment for the service detailed that staff had access to a policy on the control, storage, disposal, recording and administration of medicines. A copy of the policy was not available in Birwood for staff to view and the Acting Manager had to access a copy via the organisations intranet. The acting manager was advised to print a hard copy and to also obtain a copy of guidance issued by the Royal Pharmaceutical Society of Great Britain for staff to reference. The acting manager reported that staff had completed medication training however examination of training records revealed that some staff required refresher training and / or specialised training for the administration of diazepam. The Acting Manager confirmed that this would be addressed as a matter of priority. An identification system had been established to help minimise administration errors and a record of staff authorised to administer medication, together with sample signatures was available for reference. No assessments of competency had been completed. Medication was stored in two lockable cabinets. Examination of Medication Administration Records (MAR) revealed that there was no audit trail, as the number of tablets, date received and the details of the person checking medication into the home had not been recorded. Furthermore, it was noted that two residents were prescribed Sodium Valporate Enteric coated tablets 200mg (a drug used to control epilepsy) and that staff had sometimes been administering medication from one stock for both residents as the individual balances were incorrect. The acting manager rectified this during the visit. None of the people using the service self-administered medication at the time of the visit. Birwood DS0000021516.V360218.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. 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 available evidence including a visit to this service. Systems have been developed to listen and respond to complaints however the management of personal finances is in need of further review, in order to fully protect the welfare of vulnerable people. EVIDENCE: The Registered Provider (Community Integrated Care) had developed a corporate complaints procedure. The procedure included appropriate timescales and the contact details of the Commission for Social Care Inspection. An accessible version was also available for reference and copies of the procedure were available in each person’s care file. The Annual Quality Assurance Assessment for the service detailed that no complaints had been received since the last visit and this was verified by checking the complaints record for the service. Likewise, the Commission had received no complaints about Birwood. The people living in Birwood were observed to be relaxed and comfortable in their home environment. Staff spoken with demonstrated knowledge of the complex communication needs of the people they cared for and information on how to communicate with the people using the service was available within individual files viewed. Records showed that the Registered Provider had developed an adult protection procedure and a whistle-blowing policy. A copy of the local authority procedures was not available in the home for staff to reference at the time of the visit. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 18 Electronic training history records showed that seven out of the eight staff had completed training in the Protection of Vulnerable Adults from Abuse and the acting manager and staff spoken with demonstrated a satisfactory understanding of how to recognise and respond to suspicion and / or evidence of abuse. The Annual Quality Assurance Assessment (AQAA) for the service detailed that one safeguarding referral and investigation had been made / undertaken in the last twelve months. The investigation concerned suspected financial irregularities in the home and resulted in the dismissal of a senior member of staff. The employee has since been referred for inclusion on the Protection of Vulnerable Adults register and the Registered Provider has also reimbursed each service user for loss of personal monies. The AQAA detailed that the Registered Provider has developed procedures on the management of service users money, valuables and financial affairs. Examination of records confirmed that the finances of each service user are also checked / audited by a service manager each month. Examination of financial expenditure records revealed that the arrangements for withdrawing large sums of money from service user’s accounts for purchases remain in need of review, as there were occasions when the representatives of the people using the service had been written to, seeking approval for withdrawals after the money had been withdrawn or spent. This issue requires further attention in order to protect the welfare of vulnerable people. Birwood DS0000021516.V360218.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally well maintained however the external grounds are in need of attention in order to provide the people living in the home with attractive and accessible gardens. EVIDENCE: Birwood is a three-bedroom bungalow in a residential area of Huyton. The property is well placed for accessing local amenities and fits in well with other domestic homes in the area. The home was warm, clean and nicely decorated with a homely atmosphere. Shared space within the home consists of a lounge, open dining room and kitchen, office, laundry and enclosed back garden. These rooms are comfortably furnished and decorated. The property also had one adapted bathroom for use by the people living in the home, which was equipped with a ‘Kingcraft’ easy bath. The landlord (Maritime Housing) undertook monitoring visits and hired contractors to maintain the building as and when required. The Registered Provider also employed a maintenance person who was responsible for minor Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 20 maintenance. Jobs in need of attention and / or hazards were recorded in a maintenance book. At the time of the visit a maintenance and refurbishment plan could not be located. A tour of the premises confirmed that the property had been fitted with a new kitchen, floor covering and cooker since the last visit. Contract gardeners were observed to be on-site during the visit, however the boarders and hedges were generally unkempt due to budget constraints. Furthermore, the gardens to the rear of the home had not been landscaped or made safe and fully accessible as previously proposed. The acting manager also expressed concern regarding the condition of the ramp at the front of the bungalow as parts of the anti-slip surface were worn / damaged. Action should be taken to address these issues. Each of the people living at the home has their own room and these were found to be personalised with the person’s own belongings. The Annual Quality Assurance Assessment (AQAA) for the service detailed that policies and procedures had been developed for communicable diseases and infection control and to safeguard health and safety. Birwood DS0000021516.V360218.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of records associated with the recruitment and training of staff is in need of review, in order to provide evidence that the welfare of the people using the service is safeguarded. EVIDENCE: Birwood had a team of eight people, which included an Acting Manager and seven support workers. Discussion with staff and examination of the staff rota confirmed that two staff were on duty during the day and one staff member on duty at night. The Acting Manager reported that he provided direct care and support to the people using the service and that he was allocated supernumerary time one day a week in order to undertake management duties / administration. The Annual Quality Assurance Assessment (AQAA) detailed that the Registered Provided (Community Integrated Care) had a policy on recruitment including redundancy. Recruitment was coordinated by the Registered Provider’s Human Resources Department. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 22 The Acting Manager reported that no new staff had commenced employment at Birwood since the last visit, except for himself. The recruitment records pertaining to the Acting Manager could not be checked, as they were not available in the home for inspection. The Annual Quality Assurance Assessment (AQAA) for the service detailed that 5 (71.43 ) of the seven staff members (excluding the Acting Manager) had achieved a National Vocational Qualification (NVQ) in Care. On the day of the visit, documentary evidence of National Vocational Qualifications was available to verify that 6 (85.71 ) staff had completed the award. The Registered Provider had a training department, which delivered certain core training. The organisation had also developed a ‘CIC academy e-learning system’ which covered induction training; core skills part 1, 2 and 3; Safety at Work; Food Hygiene; Person Centred Learning; First Aid; Moving and Handling and Communicating Effectively. Practical training was also provided for Moving and Handling, First Aid and Basic Food Hygiene. A training plan was not in place for the staff at the time of the visit. The acting manager reported that a training and development programme was sent to the service every three months, which listed a range of training for staff to access. It was not possible to fully assess the level of training undertaken by staff as training records had not been updated since 2006. Furthermore, the acting manager reported that the electronic ‘training history records’ were not up-todate as previously noted. Records checked revealed that a number of staff had not undertaken and / or were in need of refresher training for safe working practice topics and other key training relevant to their roles. Staff spoken with lacked knowledge of equality and diversity issues but demonstrated a satisfactory understanding of the principles of good care practice. Staff also confirmed that they had received induction, undertaken various training courses and received supervision during their employment with Community Integrated Care. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 23 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, 40, 41 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management of care records and systems associated with recruitment, training, financial expenditure and health and safety are in need of ongoing development in order to demonstrate that the service is run in the best interests of the people using the service. EVIDENCE: At the time of the inspection the service did not have a manager who was registered with the Commission for Social Care Inspection. The Registered Provider (Community Integrated Care) had appointed David Kelly as the Acting Manager. Mr Kelly confirmed that he was in the process of preparing an application form to apply for registration with the Commission. The Acting Manager reported that he had completed a range of training that was relevant to his role and was in the process of working towards the National Vocational Qualification level 4 Registered Manager’s Award. It was not Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 24 possible to verify this information as the acting manager’s training and recruitment records were not available for inspection. The Acting Manager had previously managed a supported living home for people with learning disabilities for approximately 5 years and had been based at Birwood since September 2007. The placement was made permanent in February 2008. Feedback received from staff via discussion and surveys confirmed the manager was supportive and approachable. For example, one person reported; “The home manager makes himself available for staff to discuss issues / problems and is supportive at all times.” Records of staff meetings were also available for reference. The Service Manager continued to undertake monthly visits to Birwood on behalf of the Registered Provider in accordance with Regulation 26 of the Care Home Regulations 2001. A monthly ‘core standards review’ process is undertaken during this visit as part of the quality assurance process. This helps to form an opinion on the standard of care provided. The acting manager was advised to update his knowledge on the quality assurance process in order to confirm that the views of the people using the service and / or their representatives are obtained periodically. Information received via the Annual Quality Assurance Assessment (AQAA) for the service confirmed policies and procedure had been developed on Health and Safety. Likewise, the dataset section of the document confirmed that equipment in the home had been serviced and / or tested. Fire records were viewed for the property. Records showed that the fire alarm system had not been tested on a weekly basis for prolonged periods of time on two separate occasions - between the period 14/01/08 to 14/04/08 and 14/04/08 to 14/06/08. A fire risk assessment had been completed and a certificate was in place to confirm the fire alarm system had been serviced periodically. At the time of the visit a certificate could not be located to verify the extinguishers had been serviced. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 25 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 2 3 X 4 X 5 3 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 X 2 X X 2 X Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA6YA6 Regulation 15 2 (b) Requirement All care plans must be kept upto-date and under review to demonstrate that the needs of the people using the service are monitored and appropriately planned for. The management of finances for Residents must be clear and accurate and show that they are managed in the best interest of Residents. All transactions must be open, transparent and in agreement with each Resident / Representative. [Previous timescale of 5/06/07 not met]. The health and welfare of the people using the service must be promoted. Access to dental and optical services must be arranged periodically to ensure the health care needs of residents is safeguarded. The Registered Person must ensure that the records detailed in Schedule 2 of the Care Home Regulations 2001 are at all times available for inspection in Birwood, to provide evidence that the Acting Manager has been correctly recruited. DS0000021516.V360218.R01.S.doc Timescale for action 05/10/08 2. YA7YA7 20 05/09/08 3. YA19YA19 12 (1) a 05/09/08 4. YA34 17 (3) Schedule 4. 05/09/08 Birwood Version 5.2 Page 27 5 YA35 17 (2) Schedule 4 An up-to-date record of all 05/10/08 training undertaken, including induction training must maintained in Birwood, to provide information on the range of training completed by the staff team. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations The Statement of Purpose should be updated to include all the criteria identified in Schedule 1 of The Care Homes Regulations 2001 are included. Furthermore, the pictures, signs and symbols used in the document, should be reviewed to ensure they are more reflective of the subject area. This will enable prospective residents to make an informed decision on the service and to understand the information more easily. Assessments of need should be kept under review to ensure the needs of the people using the service are monitored. Risk assessments should be kept under review to ensure potential / actual hazards are identified and controlled. The range and frequency of community-based activities should be developed and expanded, to enhance the quality of life for the people using the service. The menu plan should be updated and a record of the dietary intake for each resident maintained, to provide evidence that the people using the service receive a healthy and nutritious diet. Each resident should have an up-to-date Health Action Plan to ensure the health care needs of the people using the service is appropriately planned for. A record of the date received, quantity and details of the person receiving medication into the home should be clearly recorded, to provide an audit trail for all medication. DS0000021516.V360218.R01.S.doc Version 5.2 Page 28 2. 3. 4. 5. YA2 YA9 YA13 YA17 6. 7. YA19 YA20 Birwood 8. YA20 9. YA23 10. YA24 11. YA35 12. 13. YA37 YA39 14. YA41 Assessments of competency should be undertaken for all staff designated with responsibility for administering medication, to confirm staff understand the arrangements for recording, handling, safekeeping, safe administering and disposal of medicines in the home. A copy of the local authority’s safeguarding adults procedure should be obtained for staff to reference. This will help staff to fully understand the local arrangements for safeguarding vulnerable people. The maintenance of the grounds and the front ramp should be reviewed, to ensure the people living in the home benefit from safe, attractive and accessible gardens / facilities. Action should be taken to ensure all staff complete safe working practice and other key training relevant to their role, to ensure the people using the service are supported by trained and competent staff. The Acting Manager should submit an application to the Commission for Social Care Inspection to register as the Manager of the service. The Acting Manager should familiarise himself with the Quality Assurance Process operated by Community Integrated Care, to confirm the views of the people using the service and / or their representatives are obtained. This will help to provide evidence that the service is run in the best interests of the residents. The fire alarm system should be tested every week to protect the health and safety of the people using the service. Furthermore, a service certificate should be obtained and available for inspection, to confirm the Fire Extinguishers have been serviced. Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Birwood DS0000021516.V360218.R01.S.doc Version 5.2 Page 30 - 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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