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Inspection on 29/09/05 for Blackfriars

Also see our care home review for Blackfriars for more information

This inspection was carried out on 29th September 2005.

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

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This home for adults with severe learning difficulties looks after it`s service users well. The staff encourage the residents to express themselves in a constructive way enabling and supporting them to take part in as many of their favourite activities as they can. They also enable as much independence and autonomy within the home as is safe and practical.

What has improved since the last inspection?

No requirements were made at the last inspection that would have needed an improvement to be made, however, the staff are always looking for ways to improve the service that they provide.

What the care home could do better:

No requirements have been made as a result of this inspection and the management and staff of the home continue to review the service with a view to improving it.

CARE HOME ADULTS 18-65 Blackfriars 12-14 Blackfriars Oswestry Shropshire SY11 2DU Lead Inspector Mike Moloney Unannounced Inspection 29th September 2005 02:30 Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Blackfriars Address 12-14 Blackfriars Oswestry Shropshire SY11 2DU 01691 670671 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) MacIntyre Care Mrs Jane Anita Humphreys Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th April 2005 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.Jane Humphreys is the registered manager and has NVQ 4 in care and management. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was announced at very short notice and started just after lunch and lasted for two hours. This was the second inspection of this home this year and as the bulk of the Key Standards had already been assessed this inspection was focussed on those that had not. The inspection was carried out by talking with the manager, observing activity within the home and talking with the residents that were present at the time. Inspection work undertaken by CSCI is proportionate in relation to how a home has performed in the past. As Blackfriars has a consistent history of providing a good service for people this inspection was brief and focused only on a small number of “key” areas of work. As the registered manager is currently on maternity leave the home is being monitored by the manager of another home within the group. This visit was partly to establish that this arrangement is working effectively. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The home has a pre-admission assessment procedure that would identify the needs of any prospective resident. EVIDENCE: No new service users have been admitted to the home since the last inspection and therefore this standard could not be fully verified, however, the home was seen to have access to appropriate policies and procedures that would be followed should the need arise and this would ensure that anyone coming to stay at the home would find the process as smooth and stress free as possible. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): x EVIDENCE: These standards had been fully assessed at the last inspection. Looking at the records showed that they had been reviewed on a regular basis since then during staff meetings, supervisions sessions with staff and at formal reviews. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14, 15 and 16 Residents are helped and encouraged to keep in contact with their friends and make good use of the local facilities. EVIDENCE: Enthusiastic communication from the residents that were there at the time of the inspection made it clear that they are taken to a variety of places of their choice by staff from the home. One lady had just returned from an aroma therapy relaxation session and was relaxing in her chair but others showed photographs and talked of outings to Aberystwyth, Llandudno, various preserved railways, scenic routes and the possibility of a trip to Crufts. Another lady was keen to show a communication device known to the staff as a ‘Big Mac’ which recorded messages on her behalf that she could use to take messages from one staff group or group of friends to another. This lady, a wheelchair user, was obviously used to going with staff to answer the door. Old friendships are also maintained as residents are also taken to other homes where their friends live. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 10 From watching and listening to conversations it was clear that the service users are used to being and expect to be involved in general conversations with the staff. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home has appropriate systems for the administration of medication. EVIDENCE: The recording of medication was looked at and was seen to be properly completed ensuring that the correct person got the correct medication at the right time. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 12 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): x EVIDENCE: Not assessed on this occasion. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 13 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): x EVIDENCE: Not assessed on this occasion. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 14 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 The home has an appropriate recruitment process and staff training process. EVIDENCE: No new staff have started at the home since the last inspection although the home is currently in the middle of recruiting a new member of staff. The manager described the recruitment process that they are following and this included obtaining all of the checks required by law that will help protect the residents from people to whom they would be vulnerable. The staff on duty were also able to confirm that they are where they are in relation to obtaining their NVQ qualifications. Only two of the staff have yet to obtain NVQ3 and they have nearly achieved this ensuring that the residents are supported by a well trained staff team. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 15 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): 39 The home has a quality assurance process that endeavours to help to provide information about how to improve the care given by the home. EVIDENCE: The organisation requires that the manager send return of the numbers of staff who receive supervision during each month. The company also carried out the MacIntyre Customer Survey earlier this year and has recently published a response. Visits by senior managers required by Regulation 26 of the Care Homes Regulations 2001 were recorded and sent to the Commission for Social Care Inspection. Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 16 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 x 3 x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x x x Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 4 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Blackfriars Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x x x DS0000020685.V255623.R01.S.doc Version 5.0 Page 17 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.V255623.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Shrewsbury Local Office 1st Floor, Chapter House South Abbey Lawn Abbey Foregate SHREWSBURY SY2 5DE 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 Blackfriars DS0000020685.V255623.R01.S.doc Version 5.0 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!