Inspection on 18/09/07 for Blackfriars

This inspection was carried out on 18th September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Blackfriars 18/05/06

Blackfriars 29/09/05

Blackfriars 27/04/05

Blackfriars 11/01/05

Blackfriars 06/09/04

Blackfriars 25/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Blackfriars 12-14 Blackfriars Oswestry Shropshire SY11 2DU Lead Inspector Mike Moloney Key Unannounced Inspection 18th September 2007 07:00 Blackfriars DS0000020685.V350969.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 Blackfriars DS0000020685.V350969.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. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blackfriars Address 12-14 Blackfriars Oswestry Shropshire SY11 2DU 01691 670671 F/P 01691 670671 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.macintyrecharity.org MacIntyre Care Mrs Jane Anita Humphreys Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th May 2006 Brief Description of the Service: 12-14 Blackfriars is part of the MacIntyre Care Services organisation and is registered with the Commission for Social Care Inspection to provide a home to four people with learning disabilities. It is situated in a very pleasant area of Oswestry, close to all amenities and the property is in keeping with the local neighbourhood. The home is currently being run by a temporary manager. The fees are paid by the health authority on a block contract basis. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A range of evidence was used to make judgements about this service. This includes: information from the provider, records kept in the home, medication records, discussions with the staff team, tour of the premises, previous inspection reports and talking with as well as observing the care experienced by people using the service What the service does well: What has improved since the last inspection? What they could do better: There have been no requirements made as a result of this inspection. However, the staff do need to be able to talk with managers privately and therefore they do need to have more regular professional supervision sessions. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 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 Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): There have been no new residents admitted to this home for some time and therefore it was not possible to assess the admissions procedure. EVIDENCE: Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. Individuals are involved in decisions about their lives and play an active role in planning the care and support they receive. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The records of two of the service users were looked at and although the person centred plans were not complete it was clear from other records seen in the files that they were being reviewed by the acting manager. One of the staff was observed helping one of the service users with her breakfast and was heard to ask her what she wanted to eat and whether or not the way she was helping was all right. Another service user was seen to be discreetly supervised when she was making herself cups of tea and a risk assessment for this process was seen to be in place. Another service user who was seen to be reluctant to get dressed that morning was heard to be Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 10 encouraged to do so but at the same time her choice of pace was respected by the staff on duty. A variety of risk assessments were seen to have been developed with more recent ones introduced by the acting manager following a different format. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. People who use services are able to make choices about their life style and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A number of documents were seen that showed that the service users undertake a variety of activities. The records of two of the service users were looked at. Those service users would have difficulty expressing themselves verbally because of the nature of their disabilities. Those records contained information about their likes, dislikes needs and wishes. Staff explained that activities had been identified as part of the person centred planning procedure that had been developed by the home and activities had been identified to meet those needs. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 12 Records of those activities were seen in the individual’s files and the entries made by the staff were professional and sensitive particularly around any behavioural issues that they may have encountered. Staff on duty explained that some of the recent activities had bee cancelled as the home’s risk assessments did not allow the use of agency staff working on their own in the circumstances. These activities had taken place both in and away from the home, often accompanied by staff. Activities included such things as personal shopping, swimming, listening to music and exercise sessions, music therapy, aromatherapy and lunch out as well as, for some, attending a local day centre. The records also contained details of the meals that the individual service users had eaten and it was seen that they have a varied and nutritious diet and talking with the service users confirmed that it was very much to their liking. Each person who was seen eating breakfast during the visit was seen to have different things and all appeared to enjoy what they ate. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Looking at the service users’ records showed that health of each of the service users is closely monitored. Examples of the areas included in the monitoring were mental health, behavioural issues and oral hygiene. Carers on duty providing personal support to service users during the inspection were seen and heard to do so in a sensitive, cheerful and professional manner. A record of each visit to or by a health care professional was seen to be kept. Talking with the staff confirmed that these appointments had been made as and when necessary with such professionals as dentists and psychiatrists. The administration and storage of medication was looked at with storage consisting of a secure cupboard within the office area. At the time of the Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 14 inspection no controlled drugs were kept in the home. Appropriate administrative systems were seen to be in place and the records showed that they had been followed. The staff confirmed that only those who had received the appropriate training were allowed to administer the medications and that, if necessary, managers would come into the home specifically to do this if those on duty had not had the appropriate training. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. Policies and procedures have been put into place by the provider that enables allegations of misconduct or any complaint to be effectively investigated so that appropriate action can be taken to protect the best interests of the service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: From talking to and watching the service users it was clear that their access to any formal policies and procedures was severely limited by their disabilities. However, easy readable versions of the complaints procedures were seen in individual’s files and a copy of the whistle blowing policy was available to the staff. Members of staff are known to have invoked both the whistle blowing policy, complaints and vulnerable adults policies since the last inspection with investigations under the latter being currently under way. Some cash is stored for the service users living at the home. Staff on duty were able to explain the recording involved in the process ensuring that the money is accounted for. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is situated on a housing estate in Oswestry and is a bungalow that has been converted to its present use in a sensitive and practical manner that is consistent with others in the neighbourhood. It has a pleasant garden and each bedroom was decorated in an individual style. Two of the service users spoken to indicated that they were pleased with the way their bedrooms were decorated and furnished. The home has a main laundry area that is clean and well equipped. These facilities remain unchanged. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 and 36 Quality in this outcome area is good, Staff in the home are trained, skilled and in sufficient numbers to support the people who use the service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff were seen helping the residents to have their breakfasts and were heard helping some of them to get up. They did these jobs in a ‘chatty’, cheerful and sensitive manner. They also had to deal with a service user who was being quite uncooperative about getting up and this they handled in a considered and professional way. Looking at the staffing rota showed that staffing levels were being maintained at an appropriate level but that this had entailed the use of agency staff. However, both regular and agency staff on duty at the time of the inspection explained that those agency staff that were employed had been used on a regular basis and were therefore well known to the residents. Looking at the home’s training records showed that training in mandatory areas, such as manual handling and infection control, was ongoing and the induction given to new starters includes all of the necessary information. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 18 Talking with the staff confirmed that NVQ training for staff was also ongoing with over 50 of the team having achieved level 3 or above. Supervision records showed that some staff had been without supervision for some time. The organisation’s area office was visited as part of the inspection where the recruitment records were looked at and these showed that the preemployment checks required to ensure that people employed to work with vulnerable people were safe to do so had been carried out. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. The management and administration of the home is based on openness and respect and has effective quality assurance systems. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home was temporarily being managed by the manager from one of the sister homes. She has the qualifications, experience and ability to carry out this task in the absence of the regular manager. The records of the visits required under Regulation 26 of the Care homes Regulations 2001 were seen confirming that those visits do take place. Equality and diversity for the service users were seen to be promoted throughout the home within the assessments, care plans and activities. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 20 Talking with the staff and looking at a variety of records confirmed that weekly checks take place on bath water temperatures and fire detection equipment. The home also has a fire risk assessment in place. Other records seen, such as the fridge and freezer temperature records showed that food safety is routinely monitored. Accident records were looked at and these showed that such incidents were monitored by the senior management. Records showing that the safety testing of portable electrical appliances takes place at appropriate intervals were found to be maintained. Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 21 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 x 2 x 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 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 x 3 x x 3 x Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 22 no 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. Standard Regulation Requirement Timescale for action 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 Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Blackfriars DS0000020685.V350969.R01.S.doc Version 5.2 Page 24 - 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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