Inspection on 12/12/05 for Briar House

This inspection was carried out on 12th December 2005.

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

Briar House 07/11/06

Briar House 18/07/05

Briar House 02/12/04

Briar House 26/05/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Briar House 186 Bury Old Road Heywood Lancashire OL10 3LN Lead Inspector Diane Gaunt Unannounced Inspection 12th December 2005 2.00pm Briar House DS0000025493.V269781.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 Briar House DS0000025493.V269781.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. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Briar House Address 186 Bury Old Road Heywood Lancashire OL10 3LN 01706 621906 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) antric@tiscali.co.uk Mrs Anna Geraldine Ellis Mrs Anna Geraldine Ellis Care Home 3 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (1) of places Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 3 service users, to include: up to 3 service users in the category of LD (Learning Disabilities under 65 years of age). The service should employ a suitably qualified and experienced manager who is registered with the CSCI. One named service user in the category of LD(E) (Learning Disabilities over 65 years of age) may be accommodated within the overall number of registered places. 18th July 2005 2. 3. Date of last inspection Brief Description of the Service: Briar House is a large semi-detached house providing care and accommodation for up to 3 persons with a learning disability. The property provides 3 single bedrooms, along with 2 living rooms, and a large dining/kitchen area. There are well-maintained gardens to the front and rear of the property as well as parking for several cars. The home is situated in Heywood and has good access to local shops and bus routes, between Bury, Heywood and Rochdale. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 3¾ hours. The inspector spoke with one carer, the manager, deputy manager and three residents, although one resident had limited speech. A short time was spent watching and listening to staff as they worked with this resident. Requirements listed at the end of the report include 2 that had not been fully met from earlier inspections. What the service does well: What has improved since the last inspection? What they could do better: The home needs to carry on providing more training for staff, making sure each person has 5 days training a year. The kitchen floor must be made safe and electrical equipment e.g. television, CD player etc. must be tested to make sure it is safe. A new accident book should be provided. Care plans should be discussed with residents again and staff should write entries in care plans so they can be easily read. Residents and other people who have contact with Briar House should be asked what they think about the home. A supporter or volunteer should be found for the resident who has no family, friends or social worker. The procedure that tells staff what to do if a Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 6 resident is harmed should be changed so that it fits in with the Government’s and Rochdale’s procedure and a procedure should be written about how new staff should be taken on. Suitable aprons should always be provided for staff. 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. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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 Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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): None of these standards were assessed. EVIDENCE: Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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 Care plans did not always accurately record current care interventions but residents knew their assessed and changing needs which were also understood and implemented by staff. EVIDENCE: Each of the care plans was inspected and two of them discussed with residents at the same time. It was apparent that residents were familiar with their files, which they recognised by the use of a photograph on the front inner sleeve. Both had signed to say they had read the plan and one resident had written in their plan also. It was more difficult to assess whether the third resident was familiar with the plan. The plans had been reviewed with residents in July 2005 and were due for further review. It was noted some of the information on care plans with regard to personal care was in need of updating as residents had become more independent. The deputy manager was planning to review them at the time of the inspection, using new inserts so each area of need would be written out afresh to describe the up to date situation. Reviews with care managers from Rochdale SSD had been requested some time ago, one review had been held 6 weeks prior to this inspection and another over 12 months prior. The annual review was therefore due. A review for the other resident had been held at the day centre but this did not address Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 10 his stay at Briar House. The manager was in contact with the SSD and was pursuing early reviews for both these residents. It was noted not all daily entries on care plans were legible. The residents interviewed expressed satisfaction with the arrangements for their care. Improvement was noted in the arrangements for recording involvement with residents’ monies. Receipts were kept and detailed balance recording sheets had been provided but they were not always completed in full. Discussion took place with the manager regarding the introduction of money checks on each shift. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents were afforded the opportunity to make choices and exercise their independence. They retained the right to freedom of movement within defined and agreed parameters enabling them to follow their chosen lifestyles. EVIDENCE: Residents described the choices they made on a daily basis and said they had the freedom to choose whether they joined in daily activities (e.g. shopping) or not. One resident for whom there were restrictions in place with regard to freedom of movement understood these restrictions and why they were implemented. They were recorded on the care plan and on a risk assessment. Discussion with residents and inspection of care plans showed that residents were supported to maintain appropriate and fulfilling lifestyles. Two residents gave examples of their increasing independence in the area of personal care. Issues around the provision of keys to bedroom and front door were discussed, and the two residents able to express a view were clear that they did not wish to have them. This was recorded on the care plans. The building is sufficiently large to allow residents privacy when everyone is home and they were each observed moving freely around the home. The atmosphere was homely and residents were included in all conversations between staff members. A Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 12 designated smoking area had been agreed and the resident who smokes understood and adhered to it. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 Residents were given the level of personal and healthcare support they wanted and needed, enabling them to exercise choice and be as independent as they wished. EVIDENCE: Each of the residents was able to express their wishes, verbally or otherwise, and were understood by staff who facilitated these wishes within agreed parameters Residents needed varying degrees of support, requesting more on some days than others. Staff understood this and were flexible in their approach. Due to the smallness of the home and the provision of a long term, stable staff team, residents’ needs and personalities were well known. Residents each made daily choices including when to get up and go to bed, what to eat, what clothes to buy and wear, how to spend their time and how much assistance they needed with personal care. Residents were registered with local GPs and care plans recorded each contact with them and hospital consultants. Appointments were also recorded in each resident’s diary. Chiropodists, dentists and opticians were accessed as and when necessary. Staff supported residents to attend appointments at surgeries, hospitals etc. Staff were further promoting health issues by encouraging one resident to smoke less cigarettes. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 14 Medication provision was not inspected on this occasion. A medication inspection will be undertaken by a CSCI Pharmacy Inspector at a later date. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Residents were confident their views were listened to and acted on. Procedures, supported by staff training ensured residents were protected from abuse, neglect and self-harm. EVIDENCE: A complaints procedure was in place and copies had been given to each resident. These were held in the back of their care plan files. The procedure was also included in the Statement of Purpose and Service User Guide. The two residents interviewed were each able to identify people within and outside of Briar House that they could go to if they had a worry or complaint. A complaints book was held at the home but contained no entries. No complaints had been received by CSCI. The home had a copy of the Rochdale Inter Agency Procedure for the Protection of Vulnerable Adults (POVA) as well as internal procedures which included whistle blowing. It was noted the internal abuse procedure did not fully reflect the reporting and investigation of complaints as included in ‘No Secrets’ (DoH 2000) and the Rochdale Inter-agency POVA Procedure. All staff had attended POVA training and those interviewed understood the term whistle–blowing and its application in Briar House. Residents interviewed said they felt safe living at Briar House. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 The home was clean and hygienic for the protection and comfort of residents. EVIDENCE: At the time of the inspection the home was found to be clean, hygienic and odour free. All members of the staff team and residents undertook domestic duties. A domestic type washing machine and dryer were provided; staff said they were adequate for the washing required. Policies and Procedures were seen to be in place with regards to the control of infection and hazardous substances, and all staff had undertaken infection control training. Those interviewed were able to describe good practice in this area, although they did not cover their clothes when serving food. Staff said that gloves and disposable aprons were routinely used when assisting with personal care but they were waiting the delivery of disposable aprons at the time of the inspection. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 and 34 Sufficient staff were provided each shift to meet residents needs, although not all had completed foundation training. Satisfactory recruitment practices were in place for residents’ protection, although these were not supported by a written procedure. EVIDENCE: A small stable staff team was in place, the majority having been employed for 7 years. Three of the staff had achieved NVQ level 2 and the deputy also had NVQ level 3. Two carers had completed TOPSS Induction training and the most recent employee was to undertake foundation training, some elements of which both of these carers had completed. Although staff had routinely attended training events linked to the needs of residents in the past, they had not done so recently. This was an area the manager said she would explore in order to enable staff to keep abreast of current practice and to achieve the provision of 5 training days per year for each staff member. Two outstanding requirements are in place with regard to training. Two weeks rotas were inspected and showed that sufficient staff were provided to meet residents needs. The ratio of staff to residents were changed according to needs i.e. less staff were working when residents were out at day centres or work, and more were provided when residents were going out in the evening or at weekends. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 18 No new staff have been recruited to work at Briar House for a considerable time. Although a current recruitment policy/procedure was not in place, recruitment practices were satisfactory and the manager had a clear understanding of the need to protect residents through the receipt of two written references, Protection of Vulnerable Adult (POVA) and Criminal Record Bureau (CRB) checks prior to employment. All staff had been issued with contracts and copies of the GSCC Code of Conduct. Although not fully inspected on this occasion, arrangements for the supervision for staff were seen to have developed since the last inspection. These focussed on observed practice in the main, it was agreed they would be extended to include more 1 : 1 sessions. Arrangements had been made for the deputy manager to attend a supervision skills course, the manager was also planning to access this course. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Whilst the home operated adequately, residents would benefit from a manager who has undertaken management training and has more contact with the staff team. Residents’ views were listened to and taken into account when reviewing the service provided. Whilst the health and safety of residents was protected and promoted in the main, there were two areas in need of attention. EVIDENCE: The manager is also the registered provider. She is a trained nurse and although she had not practised for a number of years it was apparent in interview she had kept abreast of developments in care through the reading of journals and attending some training with staff. Rotas showed that the manager spent most weekday mornings at the house overseeing practice and receiving feedback from the deputy manager, although other staff did not see her that often. Records showed that the manager had provided formal supervision for the deputy within the last 4 months, although this was mainly observed practice rather than 1 : 1 discussion. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 20 The manager has not got a formal management qualification and as she is nearing retirement does not wish to undertake one. In light of CSCI guidance, this is acceptable in the interim period but suitable arrangements should be made for the future. Due to the size of the home and the small stable staff group, feedback with residents on their thoughts and feelings about the home is a constant and ongoing process. In addition, they were actively involved in 4 monthly residents meetings and 6 monthly care plan reviews and SSD reviews. Pictorial questionnaires were also completed with them annually and were due for renewal – although two residents who were asked whether their opinions had changed made it clear they hadn’t. Both added that they ‘didn’t want to live anywhere else’. In the past feedback questionnaires were circulated to day centre staff and positive comments received. None of the residents’ families had regular contact with the home. The manager was clear as to her responsibility with regard to health and safety, and the deputy manager was taking a four day health and safety course at the local college. With one exception maintenance checks had been completed within required timescales. Records of water temperatures were recorded on a monthly basis and seen to be satisfactory. Health and safety policies and procedures were held at the home and included COSHH and hazard identification. Two requirements made at the last inspection relating to health and safety had been met. It was noted on this inspection that the floor covering in the kitchen had split, creating a tripping hazard. The accident book was seen to record no accidents, it was noted that the home was not using the newly formatted accident book. All but one staff member had received 1st Aid training and this person was booked onto a course in January 2006. Videos to be used as refresher training for each health and safety area had been purchased and were to be introduced to staff. The Environmental Health Department had undertaken an inspection at the house 4 days prior to this inspection, two recommendations were in the process of being met. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Briar House Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 2 X 3 X X 2 X DS0000025493.V269781.R01.S.doc Version 5.0 Page 22 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 YA32 Regulation 18 Requirement Skills for Care foundation training must be provided for those staff not undertaking NVQ level 2 (Original timescale 30.08.2004). A minimum of 5 days training must be provided for each staff member each year. (Original timescale: 30.03.2004) The flooring in the kitchen area must be made safe. Electrical equipment must be tested to ensure its safety and copies of certification forwarded to CSCI.. Timescale for action 31/03/06 2. YA35 18 31/03/06 3. 4. YA42 YA42 23 23 31/01/06 31/01/06 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 Refer to Standard YA6 YA6 Good Practice Recommendations Care plans should be reviewed with residents to clearly record current needs and goals. The manager should monitor to ensure entries on care plans are legible. DS0000025493.V269781.R01.S.doc Version 5.0 Page 23 Briar House 3 4 5 YA7 YA13 YA23 6 7 8 9 10 11 YA30 YA32 YA34 YA37 YA39 YA42 The manager should continue to monitor residents’ financial records to ensure their accurate completion. An advocate or volunteer should be sought for the resident who has no contact with family or friends. The internal abuse procedure should be amended to reflect the reporting and investigation procedures included in ‘No Secrets’ (DoH 2000) and the Rochdale Inter-agency procedure. The manager should ensure suitable aprons are always available for staff when attending to personal care and preparing and serving food. Training related to the needs of residents living at the house should be provided. A recruitment policy/procedure should be written to reflect current practice. Plans should be made for the future regarding the management of Briar House. Feedback questionnaires should be circulated to other professionals in contact with the service. A newly formatted accident book should be provided. Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Briar House DS0000025493.V269781.R01.S.doc Version 5.0 Page 25 - 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!