Inspection on 15/11/05 for Bishops Corner

This inspection was carried out on 15th November 2005.

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

The inspector found 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bishops Corner 11/01/07

Bishops Corner 09/05/05

Bishops Corner 24/11/04

Bishops Corner 29/06/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Bishops Corner 23 Boscobel Road St Leonards-on-sea East Sussex TN38 OLX Lead Inspector Rebecca Shewan Unannounced Inspection 15th November 2005 09:45 Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bishops Corner Address 23 Boscobel Road St Leonards-on-sea East Sussex TN38 OLX 01424 201643 01424 421684 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) New Directions (Bexhill) Limited Mrs Teresa Hills Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. The maximum number of service users to be accommodated is eight (8) Service users must be aged between eighteen (18) and sixty-five (65) years on admission Service users with a learning disability only to be accommodated Service users with Praeder Willi Syndrome may be accommodated Date of last inspection 9th May 2005 Brief Description of the Service: Bishops Corner is a care home providing social and residential care for eight young adults with learning disabilities, in particular those with Prader-Willi syndrome and associated learning behaviours. The home is owned by New Directions (Bexhill) Limited and is situated in a quiet residential part of St. Leonards-on-Sea, being a short walk from the town’s shopping centre and railway station. The house is a large three-storey property. There is a garden with patio terrace for use by residents at the rear of the house. Accommodation is provided on two floors. There are two communal lounges, one designated for smokers, and a separate dining room. The domestic-style kitchen and laundry are suitably equipped. There is a large arts and crafts room, which is in daily use by service users, supervised by day centre staff. A variety of off-site activities are arranged, including attendance at the local college and sports centre. A people carrier vehicle is available for trips and leisure outings. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to take place in the CSCI inspection year of 2005/2006. To gain a complete overview of the standards assessed it will be necessary to read both inspection reports for this inspection year. This inspection took place during the morning and early afternoon of the fifteenth November 2005. Before the inspection papers held by the Commission for Social Care Inspection were read. The inspection of the home took three and three quarter hours. A tour of the whole home was undertaken and the Registered Manager, two directors, the Development and Liaison Officer and seven service users were spoken with. There were seven service users (known as residents) at the home at the time of the inspection with one resident was at college. What the service does well: What has improved since the last inspection? What they could do better: The home should ensure that resident review records are signed by the staff member completing them. Urgent action should be taken by the home to ensure that towels, which are used communally, are removed from the homes bathroom and toilet areas and replaced with a single use method for hand drying. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 6 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. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3&5 The home has a good staff team that are experienced and have the appropriate skills to meet resident’s needs. Resident contracts are in place and these are appropriate to the nature of the home and the expectancy of residents whilst they are resident at the home. EVIDENCE: The Manager said that potential residents were assessed and if necessary would be declined, if it were deemed that the home could not meet their needs or assist them appropriately with meeting their aspirations. Staff were observed to have the appropriate skills and experience to deliver the services and care, which the home offers. The residents who reside at the home are all currently funded by Social Services, contracts that are in place are service users specific and were found to be detailed and specify the terms and conditions of the residents stay. The Manager said that if a privately funded resident were to be admitted to the home, then a private contract would be used. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 The home has a good system in place for ensuring that residents receive an annual review, however some improvement should be made to ensure that the person completing the review signs such documentation. Residents are encouraged to have control over their lives and to exercise choice and be independent in their decision making. EVIDENCE: One resident had had an annual review within the last month, the manager said that these records had been sent to the relevant professionals. Therefore the previous inspection requirement that one service user has an annual review completed has been met. However, this review was noted as being well documented but had not been signed by the person completing it. The promotion of independence is key to the residents living a full and independent life. The home is run to ensure that the resident’s are encouraged to maintain their independence in making choices and decisions relating to their daily living and their life outside of the home. Any information relating to service user choice or decision-making is recorded in the service users care plan. Where assistance is given by a person from outside of the Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 10 home (i.e. clinical psychologist or psychiatrist), this is also recorded in the care plan. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 – 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 Residents are treated with respect and there is a good rapport between staff and residents of the home and other community services. EVIDENCE: Residents are actively encouraged to go shopping once a week and to attend events held in the local community such as going to the local pub, swimming, horse riding and the gym. Residents are assisted to maintain attendance to the homes in house day centre from 9am to 5pm, Monday to Friday. All residents attend college courses and two residents have jobs. Where it is appropriate residents are encouraged to maintain relationships, unless it is detrimental to their health or mental well being. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 21 Staff and residents have a good rapport. Residents are treated with respect and dignity when being provided personal care by staff. Resident’s dying/critical illness wishes are recorded where this information has been made available. EVIDENCE: The Manager said that personal care is provided minimally and that nursing care is not provided by the home. Staff were observed encouraging residents to maintain good levels of personal hygiene, to eat a healthy diet and maintain an individual exercise regimes. The Manager said that the home records resident’s wishes in the event of dying or critical illness, where this information has been obtained and that residents wishes would be respected until such time that the home is unable to meet the needs of the resident. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 13 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): 23 The homes procedures, processes and staff training should protect service users in the event of an allegation of abuse. EVIDENCE: Records viewed showed that Protection of Vulnerable Adult training is carried out by New Directions on a yearly or as required basis. The Manager said that advocacy services are accessible to residents if required. Residents are protected from abuse, neglect and self-harm at all times. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 14 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): 25,27,29 & 30 Resident bedrooms were comfortable and residents are encouraged to have their personal possessions around them. An Infection Control policy is in place, although there is a need for the home to ensure that appropriate infection control measures are in place at all times. EVIDENCE: Resident’s bedrooms are pleasantly decorated and personal belongings were evident in the three resident’s bedrooms viewed. It was evident resident toilets and bathrooms were plentiful in number and provided appropriate privacy. Two residents have en-suite facilities (toilet, bath and hand basin) in their bedrooms. The home does not currently have any aids or specialist equipment in place. The Manager said that the current residents are fully independent in their mobility, however should a resident require an aid or item of specialist equipment then the home would be able to obtain it. The home has a sanitary waste contract in place. It was evident from the tour of the premises that towels were present in all of the home’s communal bath Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 15 and toilet areas. The infection control hazard implications of towels, which could be deemed as for use communally, were discussed between the Manager and the Inspector at the time of the inspection and an immediate requirement was made. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 16 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): 35 The home has good systems and processes in place for staff training. EVIDENCE: Individual staff training files were viewed and it was evident that staff training in First Aid, Fire Safety, manual handling, Health and Safety, food hygiene, Protection of Vulnerable Adults, Prader-Willi Syndrome, behaviour management, risk assessing, managing relationships and behaviour management. The staff induction-training package was viewed and this was found to be comprehensive in content. The Manager said that new staff are required to complete this within six weeks of commencing their job, although this time can be extended if necessary. The home also has Foundation training in place which staff complete after induction training, this is to be completed by new staff within six months of being in employment. The aim of the foundation training is to prepare staff to undertake a National Vocational Qualification (NVQ) if they have not already obtained one. Although there is a good induction and foundation training package in place, New Directions are currently in the process of revising both training packages. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 17 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): 38,39 & 41 Effective Quality Assurance procedures are in place and appropriate action is taken to address issues highlighted by responses received by the home. EVIDENCE: During the inspection it was evident that the Manager operates an open door policy and is available to residents and staff at any time whilst she is on duty. The homes Manager and staff work in a co-operative manner in order to achieve the aims and objectives of the home. Quality Assurance questionnaires were given to relatives and visitors to the home in October 2005. The Manager said that once all the responses had been received they would be published and made available for staff to see. It was evident that the home has taken the necessary actions to address any issues raised from questionnaire responses received to date. Records were also viewed for the monthly staff and resident meetings that are held. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 18 The previous inspection requirement that Regulation 26 visits are carried out within the home and that a copy of the report is sent to the CSCI, has now been met in full. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X 3 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 X 3 X 3 2 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bishops Corner Score 3 X X 3 Standard No 37 38 39 40 41 42 43 Score X 3 3 X 3 X X DS0000021416.V265644.R01.S.doc Version 5.0 Page 20 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 YA30 Regulation 13 (3) & (4) (a) (c) Requirement That towels are removed from the home’s bathroom and toilet areas and replaced with a single use method for hand drying. This is an immediate requirement. Timescale for action 15/11/05 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 YA3 Good Practice Recommendations That resident review records are signed by the person completing them. Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 Bishops Corner DS0000021416.V265644.R01.S.doc Version 5.0 Page 22 - 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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