Inspection on 10/11/05 for Bisley Drive (18)

This inspection was carried out on 10th November 2005.

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

The inspector found 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

Bisley Drive (18) 11/11/08

Bisley Drive (18) 05/12/06

Bisley Drive (18) 22/06/05

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Blenheim House

Prince Bishop Court

Park View (15)

Craigmore House

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

CARE HOME ADULTS 18-65 Bisley Drive (18) 18 Bisley Drive South Shields Tyne and Wear NE34 0PY Lead Inspector Miss Nic Shaw Unannounced Inspection 10th November 2005 8:00 Bisley Drive (18) DS0000062835.V253407.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 Bisley Drive (18) DS0000062835.V253407.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. Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bisley Drive (18) Address 18 Bisley Drive South Shields Tyne and Wear NE34 0PY 0191 454 4871 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) Real Life Options Care Home 7 Category(ies) of Learning disability (7), Learning disability over registration, with number 65 years of age (7), Physical disability (7), of places Physical disability over 65 years of age (7), Sensory impairment (7), Sensory Impairment over 65 years of age (7) Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 2005 Brief Description of the Service: Bisley Drive was first opened in January 2005. The building, which is leased to Real Life Options by the Local Authority and was formally a childrens home, has undergone extensive alteration and now provides a short break service for up to seven people who have a learning disability. The service cannot provide nursing care. The home is a large detached two storey building. Accommodation comprises of a lounge, conservatory and dining room. All bedrooms are singe occupancy and all benefit from ensuite toilet and shower facilities. Two of the bedrooms are located on the ground floor and are suitable for people who use a wheelchair. The remaining bedrooms and staff sleep-in room are located on the first floor, access to which is by a flight of stairs and are therefore not accessible to people who have a physical disability. There is a small garden and parking facilities to the rear of the building. The home is situated a short distance from the town centre of South Shields where facilities such as shops, public houses, librarys and churches can be easily accessed. The home benefits from its own transport which has been adapted to make it accessible to people who use a wheelchair. Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took 4.5 hours to complete and was a scheduled unannounced inspection. The inspection began at 8.00am in order to observe the routines of the home over the breakfast period. Time was spent talking to the five guests as well as the manager and three staff. A sample of records including care plans and staff files were examined and a tour of the premises, including all communal areas and one of the guest’s bedrooms took place. The people who use the short break service prefer to be called guests and this will be reflected throughout this report. The judgements made are based on the evidence available on the day of the inspection. What the service does well: The building offers the guests a comfortable homely environment in which to relax during their short break. The atmosphere in the home is warm, welcoming and friendly and there is a nice rapport between the staff and guests. Staff spoken to said that they liked working for Real Life Options. They said they felt valued, are provided with lots of training, and felt that they are able to provide guest’s with real choices when staying at Bisley Drive. The guests said that there is plenty for them to do when staying at Bisley Drive. The manager is able to increase the number of staff on duty whenever she needs to so that a variety of leisure activities can take place. Staffing levels are also increased when there are guests staying at Bisley Drive who have high care needs. Staff and guests said they liked the manager and found her to be approachable. The guests said that if they were unhappy they would have no hesitation in approaching the staff or manager. Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bisley Drive (18) DS0000062835.V253407.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 Bisley Drive (18) DS0000062835.V253407.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): 1 Information is available to inform guests that the service will be able to meet their needs. EVIDENCE: The manager and staff are in the process of up-dating the Service User Guide in order to reflect the recent staff changes in the home. Once completed the manager stated that it is her intention for a copy to be placed in each guest’s bedroom. A copy will also be available to guests and their relatives in the entrance foyer of the home. As discussed during the last inspection the home has one emergency bed and written guidelines inform staff of the information they need to obtain prior to accepting a guest in an emergency situation. This procedure, however, does not include obtaining a basic needs assessment and risk assessment as part of the process. This is necessary in order to ensure that the service will be able to meet the needs of a guest admitted to the home in this way. Bisley Drive (18) DS0000062835.V253407.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&9 The health and personal care needs recorded in the care plans generally reflect the guests physical, emotional and social care needs. However, these need to be further developed to ensure that the guest’s welfare is fully promoted. Guests are supported to take risks and make decisions. This means that they can enjoy a range of activities as part of living an independent lifestyle. However, risk assessments are not carried out prior to introducing new activities, which could compromise the safety of the guests. EVIDENCE: Records examined confirmed that during the last monitoring visit to the home by the home’s line manager it was identified that an audit of the guests care plans was needed. This was evident from the sample of those guests files viewed, although it was apparent that the process of up-dating these had begun with the manager obtaining an up-to-date social work assessment for each guest. Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 10 Staff spoken to were clear of the action they should take to meet the needs of the guests who were staying at Bisley Drive, however, information contained within the social work assessment and other professional assessments such as those provided by Clinical Psychologists were not reflected in the care plan. This was of particular significance in relation to the risks associated with one guest’s potential behaviour and an immediate requirement notification was issued to the manager who agreed to address these issues on the day of the inspection. The philosophy of Bisley Drive is to provide opportunities for the guests to try new leisure activities during their stay. Risk assessments need to be carried out prior to introducing new activities to the guests so that any potential hazards are identified and minimised. This was discussed with the manager during the inspection who confirmed that it was her intention to provide staff with training to enable them to implement this process. Bisley Drive (18) DS0000062835.V253407.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): 14 Guests are supported by the staff to take part in a range of leisure activities in the community. This ensures that during their stay at Bisley Drive guests enjoy a fulfilled active lifestyle. EVIDENCE: The guests spoken to said that there was lots for them to do during their stay at Bisley Drive. They spoke enthusiastically of a recent trip to the bowling alley and were planning an outing to the pub that evening. In order to expand upon leisure opportunities for the guests the staff are arranging trips further away. An example of this is a forthcoming trip to a motor show. Photographs of activities have been developed into collages, framed and displayed throughout the home. It is the philosophy of the service to provide guests with a “holiday” when at Bisley Drive. As such guests are able to choose not to attend their day centre during their stay and instead take part in leisure activities as part of their holiday. Staffing levels are provided to reflect this. On the day of the inspection two of the guests had decided not to go to the day centre and instead one of them had chosen to go for a pub lunch. Opportunities are also provided for the guests to take part in activities in the home and one of the guests showed the greetings cards they had recently been making. Bisley Drive (18) DS0000062835.V253407.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): 20 The health of the guests is protected by the medication policies and procedures, however, some of the staff require further training in this area. EVIDENCE: The medication administration records were not examined as part of the inspection process as they were assessed as satisfactory during the last inspection. Discussion was held with the manager in relation to certified medication training for staff. The senior staff are currently completing this training and the manager acknowledged that the remaining staff team need also to receive this. Bisley Drive (18) DS0000062835.V253407.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): 22 The home has a complaints procedure, however, as yet neither the guests nor their family have been given a copy of this. This could mean that their views and opinions of how the service could be improved may not be expressed. EVIDENCE: Guests spoken to said that they would feel able to approach the manager or staff if they were unhappy whilst staying at Bisley Drive. The Local Authority complaints procedure is available to guests and their relatives in the entrance foyer of the home, however, a copy of Bisley Drive’s complaints procedure was not available in the same way, which the manager agreed would be beneficial. The complaints procedure is available in picture and symbol format in order to assist those people who have communication needs. However, as discussed during the last inspection the guests are not provided with a copy of the Service User Guide and as such not provided with a copy of the complaints procedure. Bisley Drive (18) DS0000062835.V253407.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): 24&25 The guests are provided with a warm, comfortable, homely environment, which promotes their independence when staying at Bisley Drive. EVIDENCE: Guests spoken to said that they liked their bedrooms and one guest showed their bedroom which was well maintained, bright, warm and furnished with attractive pine furniture. All bedrooms are single occupancy and equipped with a television and video. Guests said that they can bring anything they want to Bisley Drive when staying there and one guest had brought with them a video of a nativity play they had been part of. A photograph of the guest is placed on their bedroom door to enable them to easily find their bedroom and guests spoken to said that the staff always did this when they came to stay at Bisley Drive. Guests also said that if they wanted a key they could have one and choose to keep their bedroom door locked. During the last inspection concerns were expressed by the manager at the unacceptable length of time it took for the Local Authority to attend to repairs and maintenance issues. However, discussion with the manager during this inspection confirmed that this is no longer an issue of concern and that the majority of issues, such as attaching paper hand towel holders to walls, have been addressed. There were no obvious outstanding maintenance issues observed during the inspection. Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 15 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): 34 The procedures for the recruitment of staff was not shown to be robust and therefore may not provide the safeguards necessary to offer protection to the guests. EVIDENCE: The manager stated that it is the policy of the organisation to obtain two written references and an Enhanced Criminal Records Bureau check prior to offering prospective employees a position within the home. However, in one staff file examined one reference was not satisfactory and the referee had advised the manager to contact them, however, no evidence was available that the company had followed this up with the referee or discussed the contents of the reference with the employee. In other staffs file examined references were not always available and in one instance there was no evidence that an Enhanced Criminal Records Bureau check had been sought. Records examined confirmed that the above issues had been identified within the line manager’s monthly monitoring visit as a shortfall which must be addressed. Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37&42 The guest’s welfare is promoted by a well managed service, however, not all of the staff have received up-to-date fire instruction, which may compromise the health and safety of the guests. EVIDENCE: A new manager has been appointed since the last inspection. She has submitted her application to become the registered manager which is currently being processed by the Commission for Social Care Inspection. Guests spoken to said that they liked the manager and found her to be approachable. Staff also said that they felt that the manager was fair and that they felt valued as members of a team. Environmental health and safety risk assessments are carried out and records maintained of these. However, on the day of the inspection there were no records available to confirm that the staff had received a fire instruction/drill at the required frequency. Discussion with the manager confirmed that it was her intention to arrange a fire training session, involving the showing of a video together with a questionnaire for staff to complete, at the next team meeting. However, in view of the potential risks associated with one guest’s behaviour it Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 17 was advised that all staff be given a fire instruction without further delay and an immediate requirement form was issued to the manager in relation to this issue. A fire risk assessment for the building was requested but not available on the day of the inspection. This needs to be completed and kept under review. The manager and home’s line manager have since contacted the Commission for Social Care Inspection to advise that records had been found which indicated that the nightstaff had recently received a fire instruction and that a fire risk assessment had been completed for the building. However, as stated earlier in the report, judgements made are based on the evidence available on the day of the inspection and as such these issues remain as requirements of the report. Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 18 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 2 X X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bisley Drive (18) Score X X 2 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X 2 X DS0000062835.V253407.R01.S.doc Version 5.0 Page 19 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 YA1 Regulation 5(2) Requirement A copy of the Service User Guide must be provided to each guest. (Timescale not met 30th September 2005). The guests care plans must be in sufficient detail to guide staff of the action they need to take to meet their assessed needs. Risk assessments must be carried out prior to introducing new activities to the guests. (Timescale not met 30th September 2005) All staff who administer medication should receive certified training in this area. A copy of the complaints procedure must be provided to each of the guests.(Timescale not met 30th September 2005). Evidence must be available to confirm that a thorough recruitment procedure has been carried out. All day staff must receive a fire instruction/drill every six months and nightstaff every three months. A fire risk assessment must be DS0000062835.V253407.R01.S.doc Timescale for action 31/03/06 2. YA6 15(1) 31/12/05 3. YA9 13(4)(b) 31/03/06 4. 5. YA20 YA22 18( c )(i) 22(5) 30/11/05 31/03/05 6. YA34 19(1)(a) 31/12/05 7. YA42 23(4)(e) 10/11/05 8. YA42 23(4)(a) 31/12/05 Page 20 Bisley Drive (18) Version 5.0 completed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Bisley Drive (18) DS0000062835.V253407.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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 Bisley Drive (18) DS0000062835.V253407.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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