Inspection on 27/02/06 for Brett Vale Residential Homes Ltd

This inspection was carried out on 27th February 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 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Brett Vale Residential Homes Ltd 13/10/08

Brett Vale Residential Homes Ltd 18/10/06

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Brett Vale Residential Homes Ltd Granary Barn, Sulley`s Farm Lower Raydon, Hadleigh Ipswich Suffolk IP7 5QQ Lead Inspector John Goodship Unannounced Inspection 27th February 2006 13:30p Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 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 Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 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. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Brett Vale Residential Homes Ltd Address Granary Barn, Sulley`s Farm Lower Raydon, Hadleigh Ipswich Suffolk IP7 5QQ 01473 827497 01473 822785 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) Brett Vale Residential Homes Limited Mr Vincent Bodjawah Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30 June 2005 Brief Description of the Service: Brett Vale is a privately owned care home providing personal care and accommodation to nine younger adults with learning disabilities. The Home’s statement of purpose gives emphasis to caring for people with challenging behaviours. Brett Vale provides accommodation within a barn conversion and is located in a rural area, close to the village of Raydon, southeast of Hadleigh. Accommodation is all in single bedrooms, seven of which have en suite facilities. There are a number of communal rooms, including a recreation room, and extensive grounds available to service users. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and followed the announced inspection in June 2005. The principal objective was for the home to evidence compliance with the statutory requirements and recommendations from the last inspection. The home was full. Residents were either at day services, at college, in their own rooms or in the communal areas. The inspector spoke to one resident in their room, and others who were in the communal areas. What the service does well: What has improved since the last inspection? What they could do better: The service users’ guide should include the views of residents on the home. Consent to any form of intrusive monitoring must be recorded. For the protection of residents, the procedure for checking with the Criminal Records Bureau must be strictly adhered to. Staff supervision should keep to a schedule to ensure that all staff receive at least six sessions a year. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 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. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 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 Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3. Sufficient information is available for prospective service users to decide whether the home will meet their needs. EVIDENCE: The Statement of Purpose was examined. It contained all the items of information required by Schedule 1 of the Regulations. The service users’ guide includes a copy of the contract with each resident. This covers in detail the financial and staffing support which the home gives to residents who go away on holiday, and which costs fall to the resident to pay. A sample questionnaire used to survey residents was included in the service users’ guide. However the standard requires that the views of service users obtained from surveys should be included. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6. Residents can expect their needs to be assessed and re-assessed on a regular basis to make sure they are being met. EVIDENCE: The manager explained that current residents had been referred by two funding authorities. Staff of one authority visited the home annually to review their residents’ care needs. Staff of the other did not visit the home, although reviews were held at the day centres for the two residents who went to them. The home however holds its own reviews with each resident to which their relatives are invited. Evidence of this was seen at the previous inspection. One review was examined on this occasion which is described in the section “Personal and Healthcare Support”. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 10 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): 14,17. Residents have access to a range of leisure activities in and around the home. Residents can expect to be offered healthy and attractive meals, with their own likes and dislikes taken into account. EVIDENCE: A resident who had been at college that day described the drama activity that they had done, with actions. They seemed to have enjoyed this. Residents were seen to be enjoying their cooked tea of Roman Holiday sausages and mash with fried vegetables. One resident was able to explain that they needed a special diet due to a digestive disorder. They pointed out the separate meal that was being prepared for them. All the food looked fresh, appetising and appealing. The two flats next to the manager’s office on the other side of the courtyard had originally been set up as self-contained units with their own cooking facilities. However these had been removed because both residents chose to eat with the others. Following comments from residents during the previous inspection, the home had recruited a carer specifically to organise and offer a wider range of Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 11 activities. There was a dedicated activities room, and in warmer weather the grounds and the surrounding countryside offered many opportunities for outdoor activities. This person was not on duty on the day of the inspection. Further assessment of the outcome of this appointment will be made at the next inspection. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 12 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. Residents can expect to be involved in decisions about their care. They can expect that their health needs will be monitored and action taken to consult the appropriate health professionals. EVIDENCE: The manager had recently been informed that the dentist which residents currently used was withdrawing from NHS work. The manager had checked the availability of NHS dentists locally. No practice was able to take on additional patients within a ten mile radius. The nearest facility for dental emergencies was Ipswich Hospital. He was investigating alternatives, short of private treatment, as he felt the residents with their care needs should not have to pay. Chiropody services were available on 6-weekly appointments. To enable one resident to be seen more frequently had required the support of the GP practice in referring. This showed that the manager was persistent in securing the right health care for residents. The home received an excellent service from the GP practice, who usually attended reviews at the home. One resident had recently been diagnosed with a serious medical condition for which they were receiving regular hospital treatment. Because of existing Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 13 medical problems, there had been a recent review with the consultant psychiatrist to check that any adverse effects of the treatment were monitored. The record of this review was available and included the next of kin who visited the resident regularly. One consequence of the treatment for the new medical condition was thought to be a higher risk of seizures. Staff monitored this when the resident was in their room by a two way monitoring alarm. This allowed instant response when a fall was heard. It appeared to be on all the time. The manager stated that the resident was happy to have this alarm for their own protection. It was not possible to ask the resident direct as they were asleep during the visit. The home must be able to demonstrate that this alarm is the most effective way to monitor seizures, and that the resident actively consents to this reduction in their privacy. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 14 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): 23. Residents are protected from abuse by the home’s policies. EVIDENCE: Following the previous inspection, the policy on the reporting of incidents and poor care practice had been revised, and now clarified that staff had a duty to report such matters. During the inspection, a resident raised a concern with the manager regarding the actions of another resident. The manager dealt with this immediately and professionally, to the apparent satisfaction of the resident. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 15 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): 26. Residents’ rooms now offer private facilities for lockable space in their rooms. EVIDENCE: New wooden bedside cabinets with a lockable drawer had been placed in all resident’ rooms. One resident was pleased to show it to the inspector. It was not clear if any residents had their own keys. Other aspects of this group of standards were inspected at the last visit and were found to be met. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 16 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): 34,36. Recruitment procedures do not give residents the protection required. Staff supervision maintains the competence of staff to give residents appropriate support according to their needs. EVIDENCE: The files of three staff appointed since the last inspection were examined. Each of them contained the required identification and information documents. Also included were the contract, record of induction, training certificates and the supervision record. However, one person had presented an enhanced disclosure certificate from a previous employer which was dated three months prior to their appointment at this home. It appeared to be for a similar post. However this work was not listed in the person’s employment history on their application form. The manager was reminded that a fresh CRB certificate must be obtained when a person changes employer, as there may be additional information not included on the certificate. Any gaps in the work record must also be clarified. The manager was required to obtain a new certificate for this person. Another person had started work one week prior to the receipt of their Disclosure certificate. No POVAFirst clearance had been received. The manager could offer no explanation why this was absent. He was advised to check with his umbrella body. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 17 Examples of supervision records were examined. Some were several months old, but the manager had more recent records which had not yet been filed. Staff were issued with a self-evaluation questionnaire which helped form the agenda of the supervision discussion. There was sometimes then a gap before the session took place. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 18 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): 37,39,41,42. Residents can expect to live in a well-run home that is managed to maximise their quality of life, and strives to meet the national minimum standards. Residents views are sought about the running of the home. The lapses in recruitment procedures left residents at some risk so the record keeping standard were not be met. Residents are protected by professional fire and health and safety audits. EVIDENCE: The manager works closely with staff, making sure that they understand the home’s aims and objectives. He also has frequent and regular contact with residents. The atmosphere in the home was good, and carers were seen to relate easily and openly with the Registered Manager. The manager had taken action to comply with the requirements and recommendations imposed at the previous inspection. An example of a service user questionnaire was present in the service users’ guide. However there should be a summary of the most recent survey and a record of any action taken subsequently in the guide. This had been a Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 19 requirement previously. The result of a previous survey had been the recruitment of a carer responsible for activities who worked Monday to Friday. Product data sheets were available for those hazardous products bought through a wholesaler. The manager was advised on ways of capturing COSHH data on domestic products bought from a superstore. All relevant products were kept in locked cupboards. A Fire Risk Assessment had been undertaken in August 2005. The fire log recorded that there were regular extinguisher checks, and the fire alarms were sounded weekly. A Health and Safety survey had been completed in September 2005 by an external company. All the hazards identified were rated as low risk, and no further action was required. The ownership of the home had been changed from a sole trader to a limited company. This had been registered by the CSCI in January 2006. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 20 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 2 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 X X 3 X 2 X 2 2 X Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 21 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 YA1YA39 Regulation 5(1) 24(1) Requirement Timescale for action 31/03/06 2 YA18 12(4)(a) 3 YA34 19 The registered person must include the views of service users in the service users’ guide. This requirement is repeated from the previous inspection. The consent of residents must be 31/03/06 recorded in their file for the use of equipment such as monitoring alarms that may intrude on their privacy and dignity. The registered person must not 27/02/06 allow any person to start work at the home until a CRB disclosure certificate, or a POVA First clearance, has been received. 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 YA36 Good Practice Recommendations The staff supervision schedule should be maintained and up-to-date, so that all staff receive at least six sessions a year. Brett Vale Residential Homes Ltd DS0000066414.V285187.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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