Inspection on 05/12/06 for Bisley Drive (18)

This inspection was carried out on 5th December 2006.

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 3 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) 10/11/05

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 Key Unannounced Inspection 1 & 5th December 2006 10:00 st Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 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) www.reallifeoptions.org Real Life Options Molly Hazel Watters 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.V313524.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 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, to improve the environment and meet the National Minimum Standards, 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 reached. 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.V313524.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days in December 2006 and was an unannounced key inspection. Time was spent talking to the manager and staff and a random selection of care plans and other records were looked at as part of the assessment of the service. In order that the views of guests and their relatives were sought a feedback form was made available. Six completed questionnaires were received from guests and six from relatives. The inspection focused on four guests, all of who have with very different needs. This is known as “case tracking”, and involves looking at what it is like, from their point of view, staying at Bisley Drive. This involved talking to the guests, watching the staff’s care practices with them and checking that information obtained from discussion with staff and observation was accurately recorded in the care records. A further three guests, who were staying at Bisley Drive during the inspection, also met with the inspector and talked of their experiences of the service. Two of the guests agreed to let the inspector look at their bedrooms and the inspector also looked at other areas of the home such as the lounge and dining room. Discussion with the manager confirmed that people who stay at Bisley Drive like to be called guests and this will be reflected throughout this report. The manager confirmed that the maximum weekly charge to guests is £62.35. What the service does well: The manager makes sure she gets a recent copy of the social work assessment so that she knows that the staff are able to meet the needs of prospective guests. There are lots of staff around so that the guests can take part in a variety of leisure activities. As well as things going on in the house, such as craft sessions, there are lots of trips out arranged for people. When guests were asked what they liked best about staying at Bisley Drive everyone said the activities. If a guest is unwell during their stay the staff make sure they get to see their own GP. Guests said that the food is nice and lots of choices are available. There is also a picture menu in the dining room to help people with communication needs. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 6 Guests said they had no complaints, but knew what to do if they were unhappy. Staff have had training so that they know what to do to stop people from being abused. The house is homely and clean and there is a small garden that the guests can use in warmer weather. Everyone is given a room of their own when they come to stay at Bisley Drive. The staff have had lots of training so that they can do their job well. As well as health and safety training this has included specialist training such as “team teach” so that staff know what to do to help people if they become agitated. As well as making sure the views of relatives, guests and the staff are obtained there are good quality assurance systems in place. For example: the staff carry out a daily check of bathwater temperatures to make sure these are not too hot. The organisation is very good at providing their information in lots of different formats, for example by using pictures, so that people with different communication needs can easily understand them. Guests said that they much preferred coming to stay at Bisley Drive compared to the previous short break service which it has replaced. What has improved since the last inspection? The Statement of Purpose and Service User Guide, (known as the home’s brochures), have been up-dated so that prospective guests are provided with up-to-date information to help them decide if Bisley Drive is the right place for them. The copy of the complaints procedure is now provided in each of the guest’s bedrooms. It is also available in the entrance foyer of the home so that guest’s are provided with the information they need on how to make a complaint. All staff who give medication have received training in how to do this safely. Since the last inspection a new boiler and kitchen doors have been fitted. Some of the policies and procedures have been changed, for example, the emergency admission policy, so that staff know what information they need before agreeing to a guest being admitted in this way. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 7 Risk assessments are carried out to make sure that any new activity the guests want to try out during their stay is safe. A very detailed fire risk assessment has been completed which lets staff know if there are any hazards and what they should do to reduce these. 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.V313524.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&2 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The guests are provided with sufficient information on which to make informed decisions about whether the service will meet their needs. The guest’s needs are always assessed prior to their admission in order to make sure that their needs can be met whilst staying at Bisley Drive. EVIDENCE: The Statement of Purpose and Service User Guide have recently been up-dated to reflect the recent staffing and structural changes within the organisation. A copy of the Service User Guide is now available in each bedroom as well as being on display in the entrance foyer of the home. This is in an accessible format, in order to address the diverse communication needs of the current and prospective guests, with the use of large print, pictures and photographs of key staff, including the inspector for the service. For those people chosen to case track a full comprehensive assessment had been obtained from their social worker. The home has one emergency bed. There are written guidelines in place to inform staff of the information they need to obtain prior to accepting a guest in an emergency situation. This includes obtaining a basic assessment and risk assessment from the social worker. Case tracking confirmed that this Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 10 procedure had been followed. Discussion with the manager confirmed that on occasion the emergency bed is inappropriately used with guests sometimes staying at Bisley Drive for many weeks. In order to address this issue the manager and the home’s line manager continually raise this as an agenda item within their regular meetings with the Local Authority, as they are responsible for placing guests in the emergency bed. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7&9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Some of the information within the care plans is good. However, detailed information in relation to the more complex needs of the guests and risk reduction strategies are not always available. This is necessary to ensure that the staff are able to effectively meet the needs of the people using the service. 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. EVIDENCE: From discussion and observation it was clear that the manager and staff understand the importance of guests being supported to take control of their own lives, and to encourage and enable them to exercise their rights and make their own decisions and choices. This is reflected by the philosophy of the service, which, for example, support guests to decide whether or not they wish to attend their day centre whilst staying at Bisley Drive. This is so that guests are able to try new leisure activities during their stay, for which generic risk assessments have began to be introduced. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 12 However, the positive interventions implemented by staff in support of the principles of person centred planning were not fully reflected in the care plans. Those care plans viewed as part of the case tracking process, although did contain basic information on the guests personal care needs, did not include enough detail to reflect some of the more complex needs of the guests. For example: one guest spoke of how staff supported them to use their moving and handling aid, yet this information was not recorded in their care plan. Staff spoken to demonstrated a wealth of information on environmental factors which may act as a “trigger” towards one guest becoming agitated, however, this too was not reflected in their care plan. Care plans also need to be developed to include comprehensive risk assessments where it has been identified in the social work assessment that there is a specific need. In one care plan there was excellent information available in relation to one guest and how they communicate in their “communication passport”. Discussion with the manager confirmed that it is her intention, with the involvement of Speech Therapists, relatives and the guests, that this standard of information will eventually be available in everyone’s care plan. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16&17 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. The right of guests to live an ordinary meaningful life whilst staying at Bisley Drive is central to the home’s aims and objectives. This ensures that the guests are able to enjoy the rights and responsibilities of citizenship. Guests are supported to take part in a wide range of activities both inside and outside the home and are able to maintain links with their families during their stay, should they so choose. This assists them to lead a full and enjoyable life whilst staying at Bisley Drive. Guests are provided with a nutritious, varied diet which helps to promote their general health and well being. EVIDENCE: Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 14 Whilst staying at Bisley Drive guests are supported by staff to take part in community life and leisure activities and everyone said that the activities available to them were “the best thing” about staying at Bisley Drive. As well as daily leisure activities in the local community, which have recently included going to the theatre, bowling, pubs, clubs, the cinema and restaurants there is plenty for guests to do in the home. On the day of the inspection guests were engaged in a craft activity with staff making a Christmas post box and Christmas cards for the home. Guests said that the staff sought their views and considered their interests when arranging activities. Sometimes this involves planning for future stays so that, for example, theatre tickets can be bought in advance. Routines are very flexible and guests can make choices in major areas of their life which, as previously mentioned, includes taking time off work so that they can have a holiday and take part in the many activities available. It was evident that activities can be changed quickly to meet individual guests needs. For example: should a guest decide not to go to the theatre, which was the case on the day of the inspection, this decision was respected. Leisure activities also extend to guests, currently not staying at Bisley Drive, who have expressed an interest in a specific leisure event. This demonstrates the commitment of the staff to providing a service where the guest’s aspirations are fully respected. One guest said that their sister visits him whilst he is staying at Bisley Drive. The philosophy of the service is to provide the guests with a holiday. As such guests are not actively encouraged to take part in cleaning and cooking activities. However, observations concluded that staff readily offer support to guests where they express an interest in doing such activities. The guests likes and dislikes in relation to food is recorded in their care plans. Guests said that the food was nice and that there was plenty for them to choose from. There is a picture menu to help the guests with this process and on the morning of the inspection pictures of breakfast cereals, fruit as well as a cooked breakfast were on display for people to choose from. Mealtimes are relaxed. The guests can have their breakfast at any time throughout the morning and staff were patient and helpful, allowing the guests the time they needed to finish their meal comfortably. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19&20 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Guests receive the support they need from staff to ensure that their personal, physical, emotional and health needs are met. The guests are protected by the homes medication policies, procedures and practises. EVIDENCE: The care plans provide guidance to staff on the guest’s preferences on how their personal care needs are to be met. During the inspection staff were observed to 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. Guests are able to bring with them anything they need which will help ensure that they are supported with their personal care in a way that they prefer. One guest said that they always brought with them their own moving and handling equipment and confirmed that the staff were competent in using this. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 16 Discussion with staff and the manager confirmed that guests continue to have access to health care professionals during their short break as required. Health care professionals, such as district nurses and speech therapists also provide on-going support and advice and inform the staff, prior to each short break, if there have been any changes in the guest’s health care needs or medication. Should a guest become ill during their stay it is the policy of the service to contact their next of kin so that they can arrange a medical appointment with their own GP. In an emergency situation, however, the emergency services would be contacted. Medication records confirmed that medication is administered to the guests appropriately. It is the responsibility of senior staff to administer medication, all of whom have completed training in the safe handling of medication. Senior staff spoken to demonstrated a good understanding of the home’s medication policies and procedures, in particular what they should do if a guest arrives with their medication in anything other than the original pharmaceutical container, which is important to ensure that the guests are only administered the medication for which they have been prescribed. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22&23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The views of guests and their supporters are taken seriously and appropriate action is taken to resolve concerns and complaints. Appropriate policies and procedures are in place, supported by staff training, which ensure that the guests are protected from abuse and neglect. EVIDENCE: Guests spoken to said that they had no complaints but if they had then they would have no hesitation in approaching the manager or staff. They said that they felt safe and that they enjoyed their stays. Records confirmed that there is a complaints procedure in place which is provided in pictures and symbols to assist those people who have verbal communication difficulties. A copy of the complaints procedure is available in the Service User Guide, which, as previously mentioned, is now provided in each of the guest’s bedrooms. The complaints record confirmed that there have been no complaints since the last inspection, although records showed that many relatives have expressed their gratitude and thanks to the manager and staff. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 18 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. These have recently been reviewed and provided in a more accessible format in order to meet the diverse communication needs of guests with the use of pictures and large print. Records showed that all staff receive training in relation to prevention of abuse during induction training. All, but the most recently recruited staff have completed training in relation to the Local Authority Safeguarding Adults procedures (formally known as Protection of Vulnerable Adults (POVA)). 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. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24&30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The guests are provided with a homely, clean, comfortable environment, which promotes their privacy and independence. 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, who use a wheelchair, said that environment was suitable to meeting their needs and that there was plenty of space to get around. Guests also confirmed that they are offered a key to their bedroom. Photographs of the guests are 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. Guests spoken to, however, said that they never used the bathing facilities as they had not been assessed by the Occupational Therapist to do so. This was discussed with the manager who confirmed that she had contacted the Occupational Therapist with a view to Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 20 them providing training for staff and undertaking individual assessments, where this has been identified as a need. All toilets and the bathroom are lockable, providing privacy for the guests. Communal space consists of a lounge, dining room, conservatory and a small multi media room equipped with a computer and play station which guests were observed to enjoy using during their stay. The bathroom floor was badly stained. This was discussed with the manager who confirmed that this had suffered from water damage and has arranged for this to be replaced. Staff confirmed that they had received training in relation to infection control during their induction. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35&36 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Guests benefit from skilled, experienced well supervised staff and the good staffing levels ensure that the guest’s needs are readily met. However, there is no training provided for staff on equality and diversity which means that the very different social, cultural and religious needs of guests may not be fully met. The service operates a robust recruitment procedure which protects guests from being looked after by unsuitable people. EVIDENCE: 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 and level 3 qualification in care, this has included training so that staff understand the care needs of people with autism, people who may become agitated and people with sensory needs. All senior staff have also recently completed risk assessment training. A training report is completed by the organisation and forwarded to the manager and is used as a management aid to ensure that training is kept up to date. None of the staff have completed training in relation to equality and diversity and the manager agreed that this would be beneficial in order to raise staff Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 22 awareness of this issue in order to more effectively meet the diverse needs of the guests. On duty during the inspection were the manager, two senior staff and two care staff. Discussion with the manager and staff and records examined confirmed that staffing levels are adjusted to reflect the care as well as the social needs of the guests. An agreement has been reached with the Commission in relation to the storage of certain staff records. It has been agreed that Enhanced Criminal Records Bureau disclosures and protection of vulnerable adult (“POVA”) first checks will be stored at the organisations Head Office and inspected by an officer nominated by the Commission. All other staff records are held in the home. Records confirmed that the staff recruitment process involves the prospective employee completing an application form. The manager and deputy manager then carry out an interview. Two satisfactory references are sought prior to offering prospective employees a position within the home. All new staff are subject to a probationary period. The manager confirmed that guests have in the past been involved in the interview process. All staff are provided with a job description which makes reference to the standards expected of them within the General Social Care Council code of practice. Copies of this code of practise were on display in the entrance foyer of the home. Staff also confirmed that they receive a monthly supervision in which opportunities are provided to discuss their training needs and the needs of the guests. Very detailed records are maintained of supervisions. Only two staff have left since the last inspection, one of whom continues to cover some shifts, which is important in terms of promoting continuity of care. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,40&42 Quality in this outcome area is excellent. This judgement has been made from evidence gathered both during and before the visit to this service. Overall management systems are effective and ensure that the health, safety and welfare of the guests is promoted. However, night staff need to receive more regular fire instruction so that they know what to do in the event of a fire. The home operates an excellent quality assurance system, based on the views of the guests, so that they know their rights will be respected and their views listened to. EVIDENCE: Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 24 Records and discussion with staff confirmed that the manager uses supervision systems to make sure staff constantly reflect upon their practice and support guests to reach their potential whilst staying at Bisley Drive. In order to meet the National Minimum standard in relation to the Registered Manager’s qualification the manager is currently undertaking a “return to nursing ” qualification, which she is hoping to complete in January 2007. There is a clear management structure composing of manager, deputy manager and senior staff. Real Life Options have a range of comprehensive policies and procedures which are continually reviewed and amended. They are also available in different formats in order to meet the diverse communication needs of the guests, which is excellent. There is a very rigorous quality assurance system which is based on the views of the guests. This involves asking guests to complete a questionnaire at the end of each stay in order to determine if anything could be improved. There are also three monthly group forums which are followed by a Newsletter which is used to keep guests and their relatives up to date with recent events. In addition to the above an independent person completes a monthly audit of the service. The focus of the audit is upon outcomes for guests. Records showed that the most recent one looked at how the service ensures the independence of guests is promoted throughout their stay. Other records are also sampled during the monthly audit including the number of accidents, whether supervisions have been completed and if there are any outstanding repairs. The monthly reports feed into a Buisness Plan for the service where areas for improvement are identified and monitored during future audits. All staff are involved in the Buisness Plan for the service which is a regular item on the team meeting agenda. Appropriate records are held in relation to accidents. The fire logbook examined confirmed that fire alarms are tested regularly and fire equipment and emergency lighting checks are carried out as recommended by the fire authority. Although all staff receive a detailed comprehensive fire instruction every six months, the manager was advised that the frequency of this needs to be increased to every three months for night staff so that they know exactly what to do in the event of a fire during the night. Records showed that a detailed fire risk assessment for the building has been completed by the deputy manager. The deputy manager is also the Regional Health and Safety Representative and has been provided with training from the organisation to assist him in this role. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 25 The senior staff carry out regular health and safety checks, which was observed during the inspection, including checks of hot water temperatures, and records are maintained of this. An independent person within the organisation has recently completed a health and safety audit of the building. Records showed that staff have completed training in relation to moving and handling, first aid and food hygiene. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 4 4 X 2 x Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 27 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 YA6 Regulation 15(1) Requirement The guests care plans must be in sufficient detail to guide staff of the action they need to take to meet their assessed needs. (Timescale not met 31/12/05) Risk assessments must be completed and relevant risk management strategies agreed where specific risks have been identified in the initial social work assessment. All night staff must receive a fire instruction every three months. (Timescale not met 10/11/05). Timescale for action 31/05/07 2. YA9 15 31/05/07 3. YA42 23(4)(e) 31/03/07 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 YA35 Good Practice Recommendations All staff should receive training in relation to equality and diversity. Bisley Drive (18) DS0000062835.V313524.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection South of Tyne Area Office St Nicholas Building St Nicholas Street Newcastle NE1 1NB 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.V313524.R01.S.doc Version 5.2 Page 29 - 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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