Inspection on 22/06/05 for Bisley Drive (18)

This inspection was carried out on 22nd June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bisley Drive (18) 11/11/08

Bisley Drive (18) 05/12/06

Bisley Drive (18) 10/11/05

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 18 Bisley Drive South Shields Tyne & Wear Address 3 NE34 0PY Lead Inspector Nic Shaw Announced Wednesday, 22 June 2005 : 10:00 nd 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. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 18 Bisley Drive Address Jarrow, Tyne & Wear NE34 0PY 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) 0191 454 4871 Real Life Options PC Care home only 7 Category(ies) of 7 x LD; 7 x LD(E); 7 x PD; 7 x PD(E); 7 x SI; 7 registration, with number x SI(E) of places 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection None 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 compromises 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 Shileds 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. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 8 hours in June 2005 and was a scheduled announced inspection. The inspection process involved talking with the manager, staff and guests and observing interactions and care practices. Feedback was also obtained from a number of questionnaires, which families and guests had completed and returned to the Commission for Social Care Inspection prior to the inspection. A meal was taken with the guests and a sample of records were examined including care plans, rotas, accident book and fire log book. A tour of the building took place which included all communal areas and a sample of the guests bedrooms. This was the home’s first inspection and as such all of the standards were assessed. 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 organisation has many policies and procedures in place, which staff follow to make sure that guests receive a good service whilst staying at Bisley Drive. There are lots of opportunities provided for the guests to take part in leisure activities. The home has its own transport, which is payed for by the organisation, so that the guests can enjoy trips further away. During their stay the guests are given the choice of whether or not to attend their day service. This means that they can enjoy leisure activities during the day as well as weekends and evenings as part of their holiday. Plenty of staff are on duty each day to enable this to happen. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 6 The staff are experienced and provided with a range of training by Real Life Options which helps them to carry out their role as care staff well. The staff spoken to said that they enjoyed their work and guests said that the staff were always happy and smiling. The organisation treats their staff well and this includes paying for a taxi to transport the acting manager to and from work each day. This means that staff are more likely to stay with this organisation which will provide continuity of care for the guests. The staff have worked hard to develop the care plans and are committed to finding different ways of communicating with the guests. This has included developing a picture menu, displaying photographs of the staff who are on duty each day and obtaining a computer programme which will change words into pictures and symbols. Whilst staying at Bisley Drive the guests are helped by the staff to take their medication and attend any pre-arranged medical appointments they may have. The environment offers the guests with a homely, clean, good quality place in which to stay. The acting manager is friendly and approachable and the guests said that they would have no hesitation in speaking to her if they had any concerns. The staff and the manager work hard to obtain the views of the people who stay at Bisley Drive and their families and this information is used to improve the service. Relatives said that their family members had enjoyed their short break at Bisley Drive and a guest spoken to said that they wanted to be able to come back more often. What has improved since the last inspection? What they could do better: 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 7 Some information needs to be given to the guests, such as the Service User guide, so that they know that Bisley Drive will be able to meet their needs and so that guests and their relatives know how to make a complaint. Sometimes building maintenance issues are not dealt with quickly enough which means that the environment could become unsafe. Although there is an acting manager, there is no registered manager, which is a legal requirement. Some policies and procedures need to be developed so that staff know what to do in certain situations. For example, if a guest becomes ill during their stay and needs to see their GP. Care plans need to be developed further so that the staff know what to do to meet all of the guests care needs. Some additional training needs to be provided to the staff, for example, the safe handling of medication, so that they can carry out their job more effectively. Nightstaff need to receive a fire instruction more regularly so that they know what to do should there be a fire during the night. The manager needs to make sure that all staff are suitable to work in the care home by obtaining confirmation from the person within the organisation, who sees the Criminal Records Bureau checks, that the staff have not been placed on the Protection of Vulnerable Adults List. 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. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3, &4 Information is available to inform guests that the service will be able to meet their needs. Guests are also able to “test” the service by being able to visit the home prior to their stay. EVIDENCE: There is a Statement of Purpose and a Service User Guide. An examination of these documents concluded that guests are provided with detailed information on the services and facilities provided at Bisley Drive. Discussion with the manager confirmed that guests are not provided with a copy of the Service User Guide, although this is available to them in the entrance foyer of the home. There are clear admissions procedures in place, details of which are included within the Statement of Purpose. This includes obtaining an up-to-date care management assessment so that the guest is assured that the service will be able to meet their needs. 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 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 10 order to ensure that the service will be able to meet the needs of a guest admitted to the home in this way. Discussion with the manager and guests and records examined concluded that guests are able to visit the home prior to using the service. Discussion with the manager confirmed that the guests pay the Local Authority for the short break service, as such terms and conditions of residency are agreed between the Local Authority and guest, not with Real Life Options, therefore this standard cannot be assessed. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,8,9,10 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 service users 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 guests. Guests know that their confidences will be kept when using the service. EVIDENCE: Of the care plans examined information was available to advise staff of the interventions needed of them to meet the guests personal care needs. Much of this information was detailed and up-to-date and of a good quality and included all aspects of the persons life. However, some of the needs identified within the assessment had not been developed into a care plan and consequently recordings made in the daily notes indicated that their health care needs had not been fully met. For example, the assessment for one guest 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 12 stated that they required a healthy diet, however, there was no detailed care plan in place instructing the staff of what this should consist of. In another assessment it had been identified that a guest could exhibit inappropriate social behaviour, however, there was no care plan in place advising staff of action they should take when this occurs. The manager agreed that some of the care plans needed further development and that the staff are currently in the process of up-dating these. Guests spoken to during the inspection confirmed that they are able to make decisions for themselves as part of living an independent lifestyle. This includes being able to decide whether or not to attend their day centre when staying at Bisley Drive. The philosophy of the service is to provide guests with a holiday, however, discussion with the manager and observations confirmed that guests can, if they so choose, participate in the day to day running of the home by helping with meal preparation and other activities such as gardening. Discussion with the manager and staff confirmed that in order to further promote guest participation in the running of the home a “guest forum” is to be introduced. Records examined confirmed that risk assessments have been carried out for a range of activities. For example; in order to promote one guests independence a risk assessment has been carried out in relation to their mobility, which involves them being able to “crawl” around the floor. Discussion with the staff confirmed that they do not carry out risk assessments prior to introducing new activities to the guests such as swimming and this is an area for future development. Discussion with the manager and records examined confirmed that staff receive training in relation to confidentiality during their induction. The guest’s records are stored in a secure location within the home. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12,13,14,15,16,17 Guests are supported by the staff to lead active fulfilled lifestyles with their rights as individual’s being respected. Opportunities are provided for the guests to try new activities, make friends and become part of the local community. This means that guests personal development and role as valued members of the community is promoted. Guests are offered a varied menu with wholesome food, which promotes their health and well being. EVIDENCE: As has been mentioned earlier in the report the philosophy of the home is to provide the guests with a holiday, as such standard twelve, which relates to providing opportunities for employment and education is not applicable. However, discussion with the manager and staff confirmed that it is also the aim of the home to ensure that the guests maintain their independent living skills. This was evident from the minutes of a recent team meeting where this was discussed and also from care plans where the level of support each guest requires is recorded. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 14 Observation and discussion with the guests and staff concluded that many opportunities are provided for the guests to take part in a range of leisure activities in the community. One guest spoken to during the inspection said they had been for a walk down to South Shields town centre and another two guests had been accompanied by staff to go bowling. That evening, as the weather was good, the staff were arranging for the guests to go for a drive down to the Beach. Photographs of other activities were on display in the lounge and included trips to Bill Quay, The Baltic, Blue Reef Sea world and a trip to Hartlepool. Discussion with the manager confirmed that when arranging each stay, although priority is given to carers holidays, hospital appointments etc, the age, gender and personal interests of the guests is taken into consideration when planning their short break. This process provides opportunities for guests to make friends. The guests confirmed that they are offered a key to their bedroom and that they can have breakfast in bed if they want to. Records examined and discussion with the guests confirmed that they are provided with a varied menu. Guests said that they liked the food that was provided and the manager confirmed that alternatives to the main meal, including a vegetarian option, is always available on request. Pictures of a range of meals are also available to assist those guests who have communication needs to choose what they would like to eat. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19,20,21 The guests are assisted by staff to maintain good quality health and receive personal support in a way that they prefer. The health of the guests is protected by the medication policies and procedures, however, some of the staff require further training in this area. The policies and procedures do not inform the guests that should they become ill or die this will be handled with sensitivity and respect. EVIDENCE: The level of support each guest requires was recorded in their care plans. Observations made confirmed that staff provide guests with support in relation to their intimate personal care in a sensitive discreet manner, carrying care tasks out in the privacy of the person’s bedroom. Care plans examined confirmed that the guests continue to have access to health care professionals during their short break. This was observed on the day of the inspection when a District Nurse visited a guest to administer their insulin. Discussion with the manager confirmed that a guest’s GP will only visit them during their stay at Bisley Drive if their surgery is within that catchment 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 16 area. If this is found not to be the case the manager stated that the locum emergency GP would be contacted. Advice was given of the need to develop a procedure to instruct staff of what action they should take in this respect. Medication records examined confirmed that medication is administered to the guests appropriately. Since the service first opened in January 2005 there have been two mistakes made in relation to the administration of medication. However, as a result of this the manager has introduced policies and procedures to prevent this from happening again. Discussion with the manager confirmed that only some of the staff who administer medication have received training in the safe handling of medication. However, whilst awaiting this training the organisation ensures that all staff complete a “medication competency programme”. There are policies and procedures in place in relation to ageing and death which includes “grieving”, “practical advice” and “support for guests and staff”. However, there is no information available to advise staff of what to do in the event of the death of a guest whilst staying at Bisley Drive. None of the staff have had training in relation to bereavement counselling. This was discussed with the manager who agreed that this would be of benefit as a guest may be admitted in an emergency due to the death of their carer. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22&23 The home has a complaints procedure, however, neither the guests or 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. Appropriate systems are in place to protect the guests from abuse and potential harm. EVIDENCE: Guests spoken to said that if they had any concerns about the service provided then they would have no hesitation in approaching the manager or staff. They said that they felt safe living in the home and that they enjoyed their stays there. Records examined confirmed that there is a complaints procedure in place which is provided in pictures and symbols to assist those people who have communication needs. However, discussion with the manager confirmed that as the guests are not provided with a copy of the Service User Guide they are also not provided with a copy of the complaints procedure. The complaints record was examined which confirmed that in response to a complaint made an investigation had been carried out. Details of the outcome had been documented in letter format and forwarded to the Local Authority as well as senior management within the organisation, for monitoring purposes. The home has its own policy and procedure documents relating to abuse which are available to staff to guide them if they have any concerns in this area. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 18 Staff spoken to confirmed that they knew what to do should they witness or suspect abuse and the majority of staff have received “alerter” training. Records examined confirmed that the guests are protected from financial abuse. Money is stored securely and detailed records of expenditure incurred during a guest’s stay is maintained, a copy of which is forwarded to their carer at the end of their stay. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29&30. The guests are provided with a homely, clean, comfortable environment, which promotes their privacy and independence. However, maintenance issues are not dealt with quickly and effectively which means that the safety of the guests may be compromised. EVIDENCE: The home was found to be clean, warm and homely. All of the bedrooms are single occupancy with en-suite toilet and shower facilities. Two of the bedrooms are located on the ground floor. These have been adapted to be fully accessible to people who use a wheelchair. Guests spoken to confirmed that they are offered a key to their bedroom. Photographs of the guests are also placed on their bedroom door to help them with their orientation during their stay. There is a separate bathroom / toilet facility on the ground floor which is equipped with a specialist bathing facility. All toilets and the bathroom are lockable, providing privacy for the guests. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 20 Communal space consists of a lounge, dining room and conservatory which plans confirm meet the space requirements of the National Minimum Standards. However, records examined and discussion with the manager and staff confirmed that since the home opened there have been a number of maintenance issues. As the property is leased by the Local Authority it remains their responsibility to attend to these issues. However, the manager stated that the time it has taken for the Local Authority to respond to maintenance requests is unacceptable. For example; some of the issues which have been raised on a number of occasions include the showers in some of the bedrooms when in use being very noisy and only providing an intermittent flow of water, a shower table which was requested for the bathroom, prior to registration, has still not been provided, the ventilation in the kitchen continues to be a major problem and the gate provided to ensure safety for guests when using the garden has fallen off. These, together with a number of other issues, are being taken up with the Local Authority by the organisation’s regional development manager. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35&36 The guests welfare is promoted and protected by a well trained, supervised staff team who are clear of their roles and responsibilities as care staff. It was not possible to judge if a the Protection of Vulnerable adults list had been checked to ensure that the staff are considered suitable to work with vulnerable adults, as such the safety of the guests may be put at risk. EVIDENCE: Discussion with the staff confirmed that they have been provided with a job description and employees handbook. The manager confirmed that the handbook contains details of key policies and procedures and aims and objectives of the service. Records examined and discussion with the manager and staff confirmed that the staff are provided with a range of training which is provided by the organisation. In addition to the NVQ level 2 qualification in care this has included positive interventions when working with people who have a challenging behaviour and communication. Each month a training report is completed by the manager and forwarded to the training department within 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 22 the organisation. The purpose of this is to ensure that training is kept up to date. On duty were the manager, deputy manager and two care staff. Discussion with the manager and staff and records examined confirmed that staffing levels are adjusted to reflect the care needs of the guests. Agency staff are used to ensure that safe staffing levels are provided and this was observed in practise on the evening of the inspection. The manager also stated that when it is necessary to use agency staff they ensure that they request those people who have already worked in the home in order to provide continuity of care for the guests. Staff files examined confirmed that an enhanced Criminal Records Bureau, (CRB), check is carried out prior to allowing a prospective member of staff to work in the care home. As the manager is not the signatory for the CRB check, they are informed in writing by the person authorised within the organisation to view the CRB checks whether this has been returned as satisfactory or not, however, the manager is not provided with information as to whether the Protection of Vulnerable adults list has also been checked, although she confirmed that the organisation does complete this check as an integral part of the recruitment process. As the registered manager is responsible for ensuring that the staff employed are “fit” and suitable to work with vulnerable adults it is advised that consideration be given to them becoming signatories for the CRB checks. In all but one instance, where there was one written reference and evidence that a verbal reference had been sought, two written references were held on the staff file, one of which was from the staff members last employer. Of the sample of job application forms examined it was evident that the staff have experience of working with adults who have a learning disability. Discussion with the manager and records examined confirmed that staff receive a formal supervision at least monthly. Issues discussed include “guest issues”, and personal development. This ensures that the home’s policies and procedures are put into practise. It also provides the staff with the opportunity of discussing future training needs in order that the guests care needs continue to be met. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 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 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) 37,38,39,40,41,42&43 Although the home continues to operate without a registered manager the guests health and safety is promoted and protected by a well managed service, where their rights as individuals are protected by a wealth of policies and procedures which are regularly reviewed and up-dated. EVIDENCE: Currently a registered manager from another care home within the organisation is managing the service until a suitably experienced manager is recruited by the organisation. Discussion with the home’s line manager during the inspection confirmed that they have recently interviewed a person who meets the management criteria outlined in the National Minimum standards and their application to become the registered manager must be submitted without further delay. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 24 The current manager described herself as being open and approachable and this was observed in practice with her interactions with the guests and staff. Records examined confirmed that there are a range of policies and procedures in place and that these are regularly up-dated by the organisation in line with recent guidance and legislation. Each month the quality assurance manager carries out an audit of the quality of the service. A quarterly health and safety audit is carried out and the views of relatives is sought through questionnaires. This information is then collated and published annually. Three days after each stay the relatives and guest are contacted and asked to provide feedback on their stay. This information is also used to improve the service. A business plan was available for inspection. This includes details of the service objectives, for example, maintaining a safe environment, delivery of the service in line with the National Minimum Standards and providing a range of activities and opportunities for the guests. Discussion with the manager and records examined confirmed that the staff are responsible for the implementation of the business plan which is discussed with them through supervisions and team meetings. Records examined confirmed that staff have received training in relation to health and safety issues such as moving and handling, food hygiene and fire safety. Risk assessments have been carried out for a range of activities carried out within the home, for example, transfer of the laundry and carrying heavy shopping. Appropriate records are held in relation to accidents. The fire log book examined confirmed that fire alarms are tested regularly and fire equipment and emergency lighting checks are carried out as recommended by the fire authority. All staff have recently received fire instruction and this is repeated every six months which involves viewing a video and a question and answer session. However, the frequency of fire instruction for nightstaff needs to be increased to three monthly. The fire evacuation procedure is discussed with the guests during their admission to the home. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 2 x Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 N/A 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 18 Bisley Drive Score 3 2 2 2 Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 2 3 B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 26 first inspection 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. 2. Standard 1 6 Regulation 5(2) 15(1) Requirement A copy of the Service User Guide must be provided to each guest. The guests care plans must be in sufficient detail to guide staff of the action they need to take to meet their assesed needs. Risk assessments must be carried out prior to introducing new activities to the guests. All staff who administer medication should recieve certified training in this area. A copy of the complaints procedure must be provided to each of the guests. The maintenance issues disucced in the report must be addressed. Evidence must be available to confirm that the POVA list has been checked for all staff members. A registered managers application must be submitted without further delay. Nightstaff must recieve a fire instruction/drill every three months. Timescale for action 30th September 2005. 31st December 2005. 30th September 2005. 30th November 2005. 30th September 2005. 30th September 2005. 30th October 2005. 30th August 2005. 30th July 2005. 3. 4. 5. 6. 7. 9 20 22 24 34 13(4)(b) 18( c )(i) 22(5) 23(2)(b) 19(1)(a) 8. 9. 37 42 8(1)(a) 23(4)(e) 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 27 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. 2. 3. 4. Refer to Standard 4 19 21 21 Good Practice Recommendations A basic assessment should be obtained from the care manager prior to admitting a guest in an emergency situation. A procedure should be developed to advise staff of action they should take should a guest, whose GPs surgery is outside of the catchment, become ill during their stay. Policies and procedures should be developed to advise staff of the action they take should a guest become ill or die during their stay at Bisley Drive. All staff should recieve training in relation to bereavement counselling. 18 Bisley Drive B52-B02 S62835 Bisley Drive V219491 220605 Stage 4.doc Version 1.30 Page 28 Commission for Social Care Inspection Baltic House Port of Tyne 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. 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