Inspection on 21/12/05 for Briar House

This inspection was carried out on 21st 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Briar House 26/11/08

Briar House 13/12/06

Briar House 12/05/05

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Briar House Briar House 89 Povey Cross Road Hookwood Surrey RH6 0AE Lead Inspector Deavanand Ramdas Unannounced Inspection 21st December 2005 10:00 Briar House DS0000062117.V267986.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 DS0000062117.V267986.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 DS0000062117.V267986.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Briar House Address Briar House 89 Povey Cross Road Hookwood Surrey RH6 0AE 01883 731547 01883 744721 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) Cavendish care Miss Tracey Lynne Spencer Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-45 YEARS. 12th May 2005 Date of last inspection Brief Description of the Service: Briar House is a detached property located in a residential area in Horley, Surrey with easy access to public amenities. The home can accommodate six service users and is registered to provide personal care for people with a learning disability. Accommodation on offer includes an office, a lounge, a kitchen, dining area, laundry and bedrooms are single with en-suite facilities. The home has a large garden to the rear of the property which is secure and accessible and private parking is available. The home is managed by Cavendish Care and the registered manager is Tracey Spencer. Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out by one inspector over a period of 4 hours. A tour of the premises took place, staff and service users were spoken to, care records and documents were examined. The inspector noted service users living at the home had communication difficulties and judgements were made based on their mood and behaviour during the inspection. The inspector would like to thank the manager, deputy manager, staff and service users for their contributions to the inspection. A CSCI business card was left at the home for information. What the service does well: What has improved since the last inspection? What they could do better: The home must make arrangements for ageing, illness and death of a service user and ensure this is reflected in service users care plans to take account of their wishes. The home must do a training plan outlining how the targets for achieving the National Vocational Qualification (NVQ) will be achieved. Briar House DS0000062117.V267986.R01.S.doc Version 5.0 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. Briar House DS0000062117.V267986.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 DS0000062117.V267986.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): 1,4&5. The homes statement of purpose and service user guide are good providing service users and prospective service users with details of the services the home provides enabling an informed choice to be made about admission to the home. The homes admission policy is good offering service users the opportunity to visit and ‘test drive’ the home. Contracts are offered by the home to ensure service users tenancy rights are protected. EVIDENCE: The manager stated the home had a statement of purpose and service user guide which were sampled. The inspector noted the statement of purpose was reviewed and updated in December 2005 and the service user guide was in widget format to make the information accessible to service users. Service users’ guides were kept in personal files for information and contained details about visitors, complaints, paperwork and the commission for social care inspection (CSCI). The manager stated the home offered prospective service users the opportunity to visit the home on an introductory basis. The inspector noted this was reflected in the charter of rights. The deputy manager stated a service user had visited the home, met the staff and other service users and had a look around the home before admission to the home. Observations confirmed a service user recently admitted to the home happy, smiling and speaking with the manager in the office. The home has no arrangements for the emergency admission of service users. The manager stated the home Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 9 offered contracts to service users that were updated in August 2005 and reflected in the charter of rights. The inspector sampled contracts and noted they were dated and signed by the manager on 10/8/05 and were kept in service users personal files for information. Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 10 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): 8&10 The systems at the home for participation are adequate ensuring service users are consulted in all aspects of life in the home. The arrangements for managing information at the home are satisfactory ensuring confidentiality is respected and the welfare of service users is protected. EVIDENCE: The manager stated the home consulted with service users on all aspects of life in the home. The inspector noted the home had local policies and a newsletter dated November 2005 that contained information about visitors, mealtimes, use of the telephone, menu and television programmes. The newsletter was in widget format to make the information accessible to service users. The inspector noted a service user participated in the weekly house shopping and the manager explained to a service user the role of the CSCI inspector to enable her to participate in the inspection process. The home had a policy on confidentiality dated August 2005 that was in widget format and in the service users guide. The inspector noted staff signatures to indicate they had read the policy and during a discussion a staff stated she was aware of the homes confidentiality policy and covered confidentiality issues in her LDAF Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 11 training. The inspector noted service users records were securely and confidentially stored in a locked cabinet in the manager’s office. Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 12 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): 13,14&15. Links with the community are good and staff support service users to become part of and participate in the local community. The arrangements for activities are adequate ensuring service users participate in leisure activities. The daily routines at the home are satisfactory and promote the independence of service users. EVIDENCE: The manager stated the home supported service users to participate in the local community and provided two house vehicles to ensure transport was readily available. The inspector noted the home had a statement on activities reflected in the aims and objectives of the home and staff supported service users to make use of local facilities including a college, a day centre and the local YMCA which was reflected in the homes activity plan. During the inspection service users went for a drive followed by lunch at local pub. The inspector noted one service user smiling and shaking his head which indicated he was happy. The manager stated the home supported service users in leisure activities and one service user went to keep fit classes. The inspector noted service users went on holiday to a local seaside resort for a week and Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 13 the manager stated service users enjoyed the holiday. The home arranges group trips and had in-house activities such as arts and crafts. The inspector noted one service user relaxing and listening to music and another watching television in the lounge. Observations confirmed staff addressed service users by their preferred names and the manager knocked on doors before entering service users bedrooms. The inspector noted service users had unrestricted access to the home and grounds and during the inspection service users were in the office, kitchen and garden. Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 14 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): 21 The policies and procedures for ageing and death needs to be improved to ensure illness and death of a service user is handled with respect and as the individual would wish. EVIDENCE: The manager stated the home supported service user through ageing and illness and had a policy on bereavement dated August 2005. The inspector noted as part of the admission process service users and their families are given a bereavement pack to complete to identify their religious and cultural customs and wishes concerning death. The manager stated families had not completed bereavement packs and the inspector noted person centred plans were in need of updating to reflect a section which covered the illness and death of a service user. The service user guide contained information about illness that was in a widget format and the information was accessible to service users but did cover areas of ageing and death. This was discussed with the manager and action has been required in respect of this matter. Briar House DS0000062117.V267986.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): The complaint process at the home is good with complaint information available to staff, families and service users. EVIDENCE: The manager stated the home had a complaint policy dated August 2005 that was in the policies and procedures folder and kept in the office. The inspector noted complaint information was in the statement of purpose and service user guide and available in widget format to make the information accessible to service users and copies of the complaint policy was in the manager’s office, hallway and some service users bedrooms. During a discussion a staff stated she was aware of the complaint policy and the manager commented the home had received no complaints since the last inspection. Briar House DS0000062117.V267986.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): 24,25,26 &27 The standard of the environment in this home is good ensuring service users have a homely place in which to live. Service users bedrooms are adequate and promote the needs, lifestyle and independence of service users. Toilets and bathrooms are sufficient and provide privacy and meet the individual needs of service users. EVIDENCE: On the day of the inspection the home was clean, comfortable, bright and free from offensive odours. The standard of décor was good with nice furniture and fittings. The manager stated the home offered access to local amenities and the inspector noted the premises were in keeping with the local community. The company had a development programme which included the provision of new gardening furniture and equipment for the home. The home had single bedrooms with en-suite facilities and bedrooms were lockable, nicely decorated and personalised with pictures, paintings, family photographs, display cabinet with ornaments, plants and television. The inspector noted one service user who had behaviour difficulties had curtains specially fitted to ensure her privacy and her wardrobe adapted to ensure her safety. Toilet and bathrooms were clean, hygienic and lockable and the inspector noted a toilet near the dining room and communal area that was easily accessible. Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 17 Briar House DS0000062117.V267986.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31&32 The management arrangement at the home is satisfactory ensuring staff have clearly defined roles and responsibilities. The competencies of staff need to improve to achieve the workforce strategy targets. EVIDENCE: The manager stated the home had a management structure that outlined the role and responsibilities of staff that was reflected in the statement of purpose. The inspector noted staff had job descriptions and copies of the General Social Care Council (GSCC) code of conduct were available in the home for information. The home employed male and female staff to reflect the gender and age of service users and operated an on-call system to provide expertise to staff who required support. The inspector noted staff were good listeners and approachable by service users. Staff had training in autism, responding to challenging behaviour and knowledge in communication which are skills necessary for supporting service users in the home. The manager stated all staff had completed the learning disability award framework (LDAF) and six members of staff were studying for the National Vocational Qualification (NVQ) but had not completed the programme due to a lack of assessor support and time constraints. The inspector noted the home had no planned programme for achieving NVQ targets and a requirement has been made in this area. Briar House DS0000062117.V267986.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): 37,40&41 The management of the home is good ensuring service users benefit from a well run home. Policies and procedures at the home are adequate ensuring the rights and interests of service users are safeguarded. Record keeping at the home is satisfactory ensuring the rights and best interests of service users are safeguarded. EVIDENCE: The home has a registered manager who has a National Vocational Qualification (NVQ) Level 4 in management and is currently studying for the Registered Managers Award (RMA). The manager provides clear leadership to the staff team and is aware of her role and responsibilities. The manager has written aims and objectives for the home, policies and procedures, contracts for service users and has displayed the homes certificate of registration and certificate of insurance for information. The process for managing the home is open and during discussions a staff stated “the management is lovely, Tracey (manager) is wonderful, everything is A1” The deputy manager remarked the home has “good rapport and communication”. Policies and procedures and Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 20 codes of practice are available in the home and some policies and procedures are in a widget format to make the information accessible to service users. The inspector noted the home had local policies that were regularly reviewed, updated, signed and dated by staff. Individual records are up to date and are securely and confidentially stored in a locked cabinet in the manager’s office. Briar House DS0000062117.V267986.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 3 X X 3 3 Standard No 22 23 Score 3 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score 3 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Briar House Score X X X 2 Standard No 37 38 39 40 41 42 43 Score 3 X X 3 3 X X DS0000062117.V267986.R01.S.doc Version 5.0 Page 22 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard NMS-YA21 Regulation 12(3) Requirement The registered person must ensure service users care plans reflect their wishes concerning death including religious and cultural customs and such information is regularly reviewed and updated. The registered person must complete a training plan outlining how the home will achieve the NVQ training targets (2005) and a copy of the plan sent to the Commission for information. Timescale for action 01/02/06 2 NMS-YA32 18(1)(a) 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Briar House DS0000062117.V267986.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 DS0000062117.V267986.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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. 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