Inspection on 05/05/05 for Bishops Croft

This inspection was carried out on 5th May 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 but made no statutory requirements on the home.

Other inspections for this house

Bishops Croft 07/12/08

Bishops Croft 12/12/06

Bishops Croft 31/01/06

Bishops Croft 01/10/04

Bishops Croft 26/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

Dovedale Court

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

CARE HOME ADULTS 18-65 Bishops Croft Bishops Lane Robertsbridge East Sussex TN32 5BA Lead Inspector James Houston Unannounced 5 May 2005 09:00 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 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 Stationary 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 Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Bishops Croft Address Bishops Lane Robertsbridge East Sussex TN32 5BA 01580 880556 01424 421684 None New Directions (Robertsbridge) Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Stephanie Winborn Care Home 7 Category(ies) of Learning Disability (LD), 7. registration, with number of places Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: 1. The maximum number of residents to be accommodated is seven Date of last inspection 1 October 2004 Brief Description of the Service: Bishops Croft is a care home providing social and residential care for seven young adults with learning disabilities, in particular those with Prader-Willi syndrome and associated challenging behaviours. The home is owned by New Directions (Robertsbridge Ltd) and is situated on the outskirts of the town of Robertsbridge with its shops and railway station. The house is a detached property with accomodation on two floors, having sufficient bathrooms, showers and toilet facilities. There are large mature gardens. Residents rooms are individually furnished and decorated in keeping with individual choices. Three rooms have en-suite facilities. The two communal lounges and dining room are furnished and decorated to a good standard. The domestic-style kitchen and laundry are suitably equipped. The premises also include a single storey building which is used as an arts and crafts workshop for residents. A variety of off-site activities are arranged and Bishops Croft has its own people carrier vehicle for trips and outings. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place during the morning and early afternoon of the fifth of May 2005. Before the inspection the inspector read the records held by the Commission for Social Care Inspection and planned those sections of the Standards to be reviewed at the inspection. The inspection itself took 5.2 hours. The Inspector read files and records and made a tour of most of the building. The responsible individual, the home’s development officer, the manager, deputy manager, three staff and five residents were spoken to during the inspection. Seven residents were living in the home on the day of the inspection. What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 6 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 Standards Statutory Requirements Identified During the Inspection Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 7 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 standard(s) 3 and 4. Staff have the skills individually and collectively to meet the needs of residents. Residents have the opportunity to visit the home before deciding if they wish to come to live there. EVIDENCE: Staff spoken to have considerable relevant experience and have had recent relevant training. The group of homes has its own development officer who was present in the home for part of the inspection. Staff said that they are able to communicate with residents and this was confirmed by discussion with residents and by observation. The manager gave examples of where the home has had, in the interests of the existing resident group, to turn down some applications to become a resident. Discussion showed that prospective residents are given the opportunity to visit the home prior to admission and a recently arrived resident spent a weekend at the home before coming to live at Bishops Croft. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 8 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 standard(s) 6,7,and 9. Thorough care plans and risk assessments are put together and regularly reviewed in order to meet the changing needs of residents. EVIDENCE: The home has substantial documentation, including a care plan based on care management assessments and the home’s own assessment. There is also a second file with current and past documents. Staff confirmed that they contribute to this process and that they have been given training about how to write in records. There are regular monthly reviews. These were inspected and found to be fully up to date. Regular full reviews are held, including one on the day of the inspection. Residents said that they have a key worker and that they were able to have a say in which staff member this is. Residents said that they can access their personal records. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 9 Detailed risk assessments are drawn up and reviewed. Staff said that they give training to residents about their personal safety. The home has a suitable policy on the action to be taken in the event of residents going missing and this is displayed in the home’s kitchen. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 10 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 standard(s) 12,14,15 and 17. Residents are finding opportunties for taking part in valued activities. Links with family and friends are encouraged. Meals promote the health and well being of residents. EVIDENCE: Staff gave examples of where residents have been enabled to take part in activities engaged in prior to entering the home for example gardening. The manager obtains college placements for residents, and they have a day service programme. Residents said they enjoy activities outside the home such as swimming, badminton, trampolineing and visits to the pub. Residents confirmed that they go on holiday regularly from the home. They have a choice of entertainment brought into the home. Group activities are planned for residents who share the same interests. One resident is able to go out alone. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 11 Staff and residents confirmed that residents’ visitors are made welcome. Staff said that they see this as an important part of their role. Food is a crucial part of the regime of the home. Residents cannot access food in the kitchen, but said that they are given choices of meals offered and like the food served. Records inspected confirmed that choices are given and recorded. The home pays careful attention to residents’ nutritional needs including factors associated with obesity. Residents are weighed regularly. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 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 standard(s) 20 and 21. The systems to hold and administer medications on behalf on residents are well kept. Details regarding residents wishes regarding arrangements to be made in the event of their death are noted to enable staff to ensure that residents wishes are respected. EVIDENCE: Drugs are securely kept. Controlled drugs are not held currently but the facility to do so exists. No residents currently administer their own medication. The record of medicines administered was inspected and is fully kept. A local pharmacist visits regularly and advises on the system, leaving a written report. The manager and senior support workers administer medication and they receive accredited training. The manager ascertains over time the wishes of residents regarding arrangements to be made after their death. These are then noted in their records and an example of this was inspected. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 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 standard(s) 22. The homes complaints procedure is suitable, and its complaints record well kept. EVIDENCE: The complaints procedure was inspected and is well drawn up. The quality assurance survey conducted at the end of last year showed that relatives of residents might be in need of new information about how it operates, and this has been done. Residents said that they were aware that they could raise matters of concern. The Commission has received no complaints regarding the home for Social Care Inspection. The home has a mechanism for dealing promptly with any matters raised. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 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 standard(s) 24,26 and 30. The home is well maintained, furnished and equipped and offers a congenial environment. EVIDENCE: The home is safe, bright, comfortable and clean. It is in keeping with the local community. The home is accessible to all residents. Furnishings, fittings and equipment are domestic in style. The home has a planned maintenance schedule, which was inspected. The manager said that the home has not had a Fire Brigade or Environmental Health Officer inspection for some time, and that there are no items outstanding. Records inspected showed that fire drills are regularly held, fire alarm points tested weekly and fire risk assessments regularly updated. Two corridor fire doors were found not to close onto their stops and the gardener/handy man and responsible individual rectified these during the inspection. The home has a large well-tended garden with extensive lawns and a vegetable garden. Since the last inspection one bedroom has been extended, and it and another bedroom have been redecorated and re-carpeted. Residents said that they are Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 15 able to bring in items of their own when coming to live in the home, and to choose the décor. Residents showed the inspector their rooms, which they said they liked and to which they have a key. The laundry is domestic in design and well sited and equipped. Residents do their own laundry with assistance as needed. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33,34,and 35. The staff group has sufficient numbers and skills to meet residents assessed needs. Staff recruitment processes to protect residents are thorough . Supervision given to assist staff to meet residents needs in some cases to be more frequent. EVIDENCE: The manager confirmed that she hopes shortly to have three staff on duty at weekends as well as during the week. There is one waking staff member on duty in the home at night. The current staff rota inspected did not have the roles of staff on it and the deputy manager added these during the inspection. There were enough staff on duty to meet the needs of residents. Staff said that staff turnover is currently low. The manager said that only very limited use is made of agency staff, and then only of staff already known to residents. Residents said that they like staff and that they are helpful. Staff said that those left in charge are always aged at least 21. The manager said that she and other managers in the group are on call and available to staff on a rota, and that the providers are also contactable. Staff confirmed that regular staff meetings are held and minutes kept. These were made available to the Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 17 inspector. The manager said that a resident’s representative now attends for part of the staff meeting. Recruitment procedures are thorough, with all the records required by regulation now being held. Staff confirmed that they receive copies of the General Social Care Council code of conduct. Staff are given contracts of employment. Staff are supervised regularly, but records showed gaps for two staff. The manager is aware of this aspect and is dealing with it. Annual staff appraisals are held. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39,40,41 and 43. The user’s guide needs to include the results of the recent survey to inform residents and stakeholders. Policies, procedures and records are well kept. EVIDENCE: The home has undertaken a survey of residents, service users, staff and linked professionals since the last inspection. The results have been studied and used to inform practice but now need to be incorporated into the service users’ guide. Policies and procedures inspected are well kept and regularly reviewed. The home’s manager will over time sign them, in addition to the owner as at present. Records inspected were found to be well kept. The home’s certificate of insurance is on display. Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x x x 3 Standard No 11 12 13 14 15 Bishops Croft x 3 x 3 3 Standard No 31 32 33 34 35 36 Score x x 3 3 x 2 Version 1.20 Page 20 H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc 16 17 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 3 Standard No 37 38 39 40 41 42 43 Score x 3 2 3 3 x 3 Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 39 Regulation 24(1) (a&b) (3) Requirement The results of the quality assurance questionnaires sent out since the last inspection should be included in the service users guide (Previous timescale of 31.1.05 not met) Timescale for action 31 May 2005 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 36 Good Practice Recommendations All staff receive supervision at least six times a year Bishops Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 22 Commission for Social Care Inspection 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 Croft H59-H10 S21053 Bishops Croft V222971 210405 Stage 4.doc Version 1.20 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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