Inspection on 02/11/06 for Boroughbridge Road (67)

This inspection was carried out on 2nd November 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Boroughbridge Road (67) 22/10/08

Boroughbridge Road (67) 23/10/07

Boroughbridge Road (67) 20/03/06

Boroughbridge Road (67) 17/05/05

Boroughbridge Road (67) 13/12/04

Boroughbridge Road (67) 10/08/04

Boroughbridge Road (67) 26/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Boroughbridge Road (67) 67 Boroughbridge Road Knaresborough North Yorkshire HG5 0ND Lead Inspector Mrs Maggie Coxon Unannounced Inspection 2nd November 2006 09:30 Boroughbridge Road (67) DS0000007902.V317997.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 Boroughbridge Road (67) DS0000007902.V317997.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. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Boroughbridge Road (67) Address 67 Boroughbridge Road Knaresborough North Yorkshire HG5 0ND 01423 869343 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) St Anne’s Community Services *** Post Vacant *** Care Home 3 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (1) of places Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Category LD(E) for one named service user already residing at the home. 20th March 2006 Date of last inspection Brief Description of the Service: 67 Boroughbridge Road is a care home registered by St Annes Community Services to provide personal care and accommodation to up to three adults with learning disabilities. The home consists of a two-storied, end of terrace house located on a busy road in the market town of Knaresborough. Local community facilities include shops, cafes and a post office. Each of the three bedrooms is for single accommodation, one of which has en suite facilities. These are situated on the first floor. Whilst the home does not have a passenger or stair lift, all areas are accessible to those residents currently living there. There are very well maintained garden areas to the front and side of the home with hard standing for parking to the rear. Information provided by the new manager on 8th November 2006 indicated that the current monthly fee for the home is £1,212.15. Additional costs include toiletries, hairdressing and chiropody. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This is what was used to write this report: • • • Information about the home kept by the Commission for Social Care Inspection. Information asked for before the inspection, this is called a preinspection questionnaire. A visit to the home that they didn’t know was going to happen. This lasted for five hours and included talking to the three residents and to care staff about how the home is run. All areas of the home were also seen and records that the home has to keep were checked. Residents’ medication was also checked to make sure that it was being properly looked after for them. What the service does well: The staff treat residents well. They make sure that they get the support that they need and are able to go to out into town, have holidays and take part in activities and trips that they want to. Residents help staff complete the forms that tell staff what support they need. These forms have the right kind of information needed for staff to support residents and there is a special place to keep information that is important but doesn’t need to be shared with everyone. People interested in living in the home can visit the home to see if they like it. This means that they can decide whether or not they move into the home. Residents are asked to say what they think about the help they get what help they would like in the future. They are asked what they think about the home so that the staff team can make changes to make things better for them. Residents can see friends and family at any time. Staff also spend a lot of time talking to the residents. This means that they can have company whenever they like although they are allowed to have quiet time as well if this is what they want. Each resident has their own room and staff keep the home clean and tidy. Residents choose what they want to eat and staff cook fresh meals every day. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Boroughbridge Road (67) DS0000007902.V317997.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 Boroughbridge Road (67) DS0000007902.V317997.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): 1, 2 and 4. Quality in this outcome area is good. A comprehensive assessment process and information provided gives prospective residents an opportunity to choose if they want to move into the home. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Well-detailed information about services offered is included in the home’s statement of purpose and service user guide. This information is made available to prospective residents so that they can decide whether or not the service can meet their needs prior to moving in. An assessment had been taken of each resident before they moved in a number of years ago and no admissions have been made since then. Whilst there are currently no vacancies there is a procedure that any prospective resident would have a pre admission assessment and a planned introductory programme including trial visits to the home and a trial placement prior to a placement being made permanent. Boroughbridge Road (67) DS0000007902.V317997.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. Residents make a number of decisions and everyday choices although more evidence of this could be produced. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Case tracking confirmed that residents’ individual personal plans are comprehensive and organized and are being regularly reviewed. They contain sufficient detail to ensure that staff know how best to meet the diverse needs of the individual in a way that promotes their independence wherever possible. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 10 Person centred planning meetings have been held for each resident in which they have had a say in the plan for changes to services needed and individuals’ wishes and agreed outcomes have been recorded. These have identified that one resident would like more days out with staff and that someone else would like to have changes made to their diet, to take more exercise and to have more trips out. Whilst staff said that these goals were being worked towards there was no written evidence of this in daily notes or elsewhere. Daily records also contained insufficient detail to indicate that service users were able to make many choices and decisions in their daily lives although observations at the visit and discussions with staff gave some evidence that this is the case. Records showed that residents can take reasonable risks subject to a personal risk assessment. Boroughbridge Road (67) DS0000007902.V317997.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): 12,13,14,15,16 and 17. Quality in this outcome area is good. The range of activities enjoyed by residents is varied and individually tailored giving them opportunities to meet their social needs. Residents are supported to develop and maintain personal relationships, thereby meeting some of their emotional needs. Meals are nutritious and offer a varied diet so residents can enjoy their meals. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Residents have a variety of activities that they participate in within their community and in the home although they are also allowed personal space when they want it. Each one had either taken or booked a holiday or short Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 12 break this year. Residents are well supported to develop and maintain personal relationships of their choosing including maintaining contact with family members. Routines in the home are very relaxed and staff were seen to speak to and support residents in a very positive and friendly way. Boroughbridge Road (67) DS0000007902.V317997.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. Residents’ healthcare needs are identified and arrangements made to ensure that these are met. They are supported by staff to take their medication as prescribed by their GP although not all staff have been suitably trained which could potentially affect the safety of residents. Residents’ personal care needs are well met. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Staff were seen to provide all support, including that concerning personal care needs, in a way that promoted residents’ privacy and dignity. Case tracking identified that each resident is registered with a GP and has been medically assessed. They attend regular appointments with various health care professionals and dentists. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 14 All of the residents have their medication administered by staff. This is well recorded and all medication is securely stored. Two of the four permanent care staff have undertaken appropriate medication training but the other two have not yet done so although they are involved in administrating medication to residents. Boroughbridge Road (67) DS0000007902.V317997.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. Systems are in place for dealing with concerns or complaints and for ensuring residents’ protection. This judgement has been made using available evidence including a visit to the service. EVIDENCE: A comprehensive complaints procedure is followed. Residents can express any dissatisfaction directly with staff or at team meetings which they can attend if they choose to. Where they are unable to verbalize concerns fully staff observe behaviours and body language to identify any dissatisfaction. There have been no complaints made since the last inspection. There is also a comprehensive adult protection procedure in operation and whilst the permanent staff have all had adult protection training during their induction period they said that they have not had refresher training this year. Twice daily checks of service users’ finances are undertaken and staff explained that there is a policy of no physical restraint in the home. Boroughbridge Road (67) DS0000007902.V317997.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 adequate. The standard of the environment is good giving residents a clean and comfortable home in which to live. Some staff have not been adhering fully to fire safety procedures however which means that at times the environment does not provide residents with a safe place to live although the manager is understood to be taking steps to address this shortfall. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The home was clean, tidy and warm throughout with the central heating system now in full operation once more. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 17 Communal areas are well maintained, decorated and furnished. Two of the residents showed me their bedrooms, which were decorated and furnished to their personal taste. Every bedroom door was wedged open however, this endangers the safety of residents and staff. The staff member who had done this said it was intended to be on a temporary basis whilst household duties were being undertaken but the wedges had still been in place some time later in the visit when the environment was checked. Other staff explained that the manager had previously come across the same practice and had reminded staff that this was unacceptable. They also reported that she had ordered authorized door closers for these doors. A formal letter has been sent to the Responsible Individual for St Anne’s Community Services regarding this matter. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 18 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): 32,33,34,35 and 36. Quality in this outcome area is adequate. The home is adequately staffed so residents can get the support they need. A lack of fire safety and other mandatory training for staff however means residents could be put at risk. Likewise a potential failure by the organization to provide staff and management with other refresher training and support for NVQ training could reduce the quality of care for residents. This judgement has been made using available evidence including a visit to the service. EVIDENCE: Sufficient staff were on duty at the time of the visit and staff rosters indicate that the home is well staffed at all times. Staff confirmed this to be the case. There are currently three full time care posts vacant that are being recruited to. These hours are covered by permanent staff working extra hours and by two agency staff with temporary contracts. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 19 No recruitment records were available as the manager was not present but no permanent staff have been employed since the last visit. New staff undertake the learning disability award framework induction and foundation training as well as basic training on abuse, moving and handling, basic food hygiene and first aid. Staff explained however that there had been no refresher training since January 2006 and their training was now out of date. The member of agency staff on duty said she had had no training from St Anne’s and had not been given fire safety training since commencing employment. Staff explained that only one of the four permanent staff has completed their National Vocational Qualification. Staff said that they have had supervision from the new manager although no record of this was available. Staff said the manager also holds regular staff team meetings part of which residents are invited to attend. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 20 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): 37,38,39,41 and 42. Quality in this outcome area is adequate. The home is well managed and there are some robust health and safety systems and procedures in operation although there are shortfalls in others, which could put the safety of residents and staff at risk. Action is being taken however to address some of these shortfalls. This judgement has been made using available evidence including a visit to the service. EVIDENCE: The previous acting manager has moved to manage a sister service on a temporary basis and a new manager has been appointed at 67 Boroughbridge Road. Staff said that the running of the home has improved since the Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 21 appointment of a permanent manager who has an open and inclusive style and that this benefits residents and staff. The manager has yet to submit an application to register with the Commission for Social Care Inspection and has yet to complete an appropriate management qualification. Staff say that they have regular team meetings. Monthly quality audits of the home are undertaken by the service manager. Residents are invited to give their views on the running of their home by attending part of staff meetings, through person centred planning meetings and informally with staff at any time. The manager and staff then develop a team plan for the service. Whilst many records are well maintained residents’ daily records are insufficiently detailed to show that their choices or goals are being met and that they can participate in as many activities as they choose. All records are securely stored. There have been no accidents to service users in the home since the last visit. Monthly health and safety checks of the environment are undertaken and recorded and many other health and safety systems are well maintained including the testing of hot water and fridge/freezer temperatures. Whilst a current gas safety certificate is in place however, no current electrical wiring certificate was available. Fire safety within the home was checked and it was found that external professional checks of the fire system and equipment were being done regularly along with weekly tests of the system by staff. Problems were identified however in that several fire doors were wedged open. A formal letter has been sent to the Responsible Individual for St Anne’s Community Services regarding this matter. Also, the fire risk assessment is insufficiently detailed to comply with current guidelines issued by the fire safety service. Agency staff have had no fire safety training since being employed and no permanent staff have had training since January 2006. New central heating boiler parts and piping have been fitted so that the system is now fully functional improving the warmth and safety of the home for residents. Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 22 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 1 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 2 3 3 X 2 1 X Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 23 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. 1. Standard YA24 YA42 Regulation 23 Requirement Fire doors must not be wedged open at any time. A formal letter has been sent to the Responsible Individual concerning this requirement. A fire risk assessment must be undertaken to comply with current fire safety service guidelines. All staff including agency staff must be provided with current fire safety training. All staff must be provided with current mandatory training. A satisfactory electrical wiring certificate must be in place a copy of which must be submitted to the Commission for Social Care Inspection. Timescale for action 02/11/06 2. YA35 YA42 13 22/12/06 3. 4. YA35 YA42 18 13 23/02/07 22/12/06 Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 24 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 YA20 YA23 YA32 YA37 Good Practice Recommendations All staff involved in the administration of medication should be appropriately trained to do so. All staff should be provided with updated adult protection training. A minimum of 50 of care staff should be qualified to NVQ level 2 or above. An application to register the new manager for the service should be submitted to the Commission for Social Care Inspection. The current manager should complete an appropriate management qualification. Residents’ daily records should be more fully recorded to evidence residents exercising choices and being supported to take part in chosen activities and attain individual goals. 5. YA41 Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Boroughbridge Road (67) DS0000007902.V317997.R01.S.doc Version 5.2 Page 26 - 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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