Inspection on 07/11/06 for Briar House

This inspection was carried out on 7th November 2006.

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

The inspector 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Briar House 12/12/05

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 Jenny Andrew Key Unannounced Inspection 7th November 2006 16:00 Briar House DS0000025493.V309700.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 Briar House DS0000025493.V309700.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. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 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.V309700.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 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. 12th December 2005 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. The weekly fees are dependent upon the assessed needs of the individual. No additional extra charges are made. The owner makes information about the service available upon request in the form of a Service User Guide and Statement of Purpose, which is given to new residents. A copy of the Commission for Social Care (CSCI) inspection report is held in the home. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection took place over three and a half hours. The inspector looked around parts of the building, checked the records kept on residents to make sure staff were looking after them properly as well as looking at how the medication was given out. The file of the newest member of staff was also checked. In order to obtain as much information as possible about how well the home looked after the clients, the deputy manager, support worker and 3 service users were spoken to and 2 of the service users also returned comment cards. Other information, which had been received about the service, over the past year, has also been used as evidence What the service does well: What has improved since the last inspection? All the electrical equipment had been tested to make sure it was safe for the staff and clients to use. The kitchen floor had been made safe by means of tape until new flooring was fitted. Staff were now wearing plastic aprons when serving food so that the risk of infection would be lessened. The system in place for clients’ monies had improved and receipts were being kept to show how money had been spent. The staff, especially the deputy manager had been on more training courses so she would better understand how to deal with abuse, managing behaviour and mental health. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 6 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. Briar House DS0000025493.V309700.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 Briar House DS0000025493.V309700.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Clients’ individual needs were assessed in full, prior to admission, ensuring staff were able to meet their needs. EVIDENCE: All three clients had lived at Briar House for some considerable time on a longterm basis. Full care management assessments had been completed in respect of each of them prior to admission. The home also had in place an assessment format that would be used for any future new admissions to the home. The clients felt their needs were continuing to be met at Briar House. Since the last inspection two people had had care management reviews, undertaken by a Social Services Department care manager. Both review documents recorded the clients were settled and one commented positively about how much progress had been made by one client with regard to her ability to make herself understood. This was also evidenced during the inspection, when this client took an active part in conversations with the inspector. The third client was due to have a review within the next month, her previous one having been done in October 2005. Briar House DS0000025493.V309700.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Clients were encouraged to be as independent as possible within individual capabilities and enabled to lead fulfilling lives. EVIDENCE: All 3 care plans were checked and one of them discussed with a client at the same time. They were kept in the laundry area so that the clients could see their files when they wanted. Each file had a photograph at the front, so that they would be easily recognisable by the clients. Whilst the care plans contained the clients basic care needs, they did not record exactly what personal care assistance they needed, for example help with washing hair, shaving etc. and no recordings were made about daily routines such as preferred times for getting up, going to bed etc. The clients spoken with said their needs were regularly discussed with them and that they were able to look in their files if they wanted to. They were also satisfied with the care and support they received from the staff. One person said “I have fun with the staff” and “they help me to do things I can’t do for Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 10 myself”. The service user with limited communication skills was seen to interact positively with the two staff on duty and it was clear they understood her needs and had an excellent relationship with her. All three care plans were regularly reviewed. Discussions with clients showed they were able to make decisions and choices regarding their day to day care, dependent upon outcomes of risk assessments. Where choices were restricted, this was recorded on the person’s file together with the reasons for the action taken. Individual arrangements were in place with regard to clients’ finances. The two people who were able to discuss their choices with the inspector said they were happy with the current arrangements and talked about what they liked to spend their money on. A solicitor held Power of Attorney for one person. Clients’ finances were checked and found to be in order. In order to further develop good practice, discussion took place about introducing a system whereby at staff handovers, staff signed to say the balance of money was correct. The deputy manager said she would implement this. Where risk areas had been identified, assessments were in place, showing what action needed to be taken to reduce the risk area. These had been regularly reviewed and updated. Briar House DS0000025493.V309700.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The range of opportunities available for clients to pursue leisure and intellectual activities reflected their diversity and social, intellectual and physical capacities. Individuality was respected and the menus showed that healthy eating was encouraged. EVIDENCE: Two clients went out to daytime occupations during the week. One had paid employment at a day centre, which she said she really enjoyed as she met lots of people there. The other person attended a day care centre, which he said he liked going to. Arrangements for the other person were made on a day to day basis, either going out shopping, for walks or for a drive in the car. If staying at home this person enjoyed knitting, colouring and reading. A recommendation was made at the last inspection for the home to purchase more age-appropriate books. This had been done but the client had shown no interest in them and reverted back to the books she had previously enjoyed. Diaries were in place for each of the clients, which recorded particular events Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 12 of the day. Some activities were recorded in the individual diaries. It was noted however, that for the person who stayed at home during the week, the recordings did not detail all the activities she had done or record places she had visited when out in the car. This should be addressed. Leisure activities enjoyed by two of the clients included, going to the cinema, pub, bingo, playing pool, eating out and shopping. One of the clients said he liked to go out with the male support worker for a drink. A pool table was in one of the lounges so that he could have a game of pool in the evenings, whenever he wanted. Staff had supported all 3 clients to go away on holiday to Blackpool, which they had chosen themselves. One client was looking forward to Christmas parties and staff had booked a Christmas pantomime. From speaking to the clients and staff on duty, it was identified the clients were also very much involved in the staff’s family social events and parties. One client said “we have fun” and another said, “I love going to parties and McDonalds”. Entertainment in-house consisted of watching television or video/music nights. One person attended church each week. She said she had taken part in a church procession in Manchester and from the way she described it, it was clear she had really enjoyed this experience. None of the clients had regular contact with relatives but one person met up with friends and an advocate. Staff encouraged the clients’ to make choices on a daily basis. Discussion with clients identified their preferred routines and choices, were respected by the staff. The layout of the building enabled the clients to have their own personal space, even when everyone was at home. The atmosphere was lively and the staff on duty interacted well with all 3 clients. It was evident the clients enjoyed their company. A designated smoking area had been agreed and the person who smoked knew this was a rule that had to be kept. The staff knew the food likes and dislikes of the 3 clients and planned the menus accordingly. Inspection of the menu records showed them to be varied and nutritious with fresh fruit and vegetables being regularly eaten. Healthy eating was encouraged by the staff as they were mindful of the need to keep clients’ weight stable. Records showed that weight was monitored regularly. Observations made on the evening of the inspection, showed the clients to really enjoy their meal. One client said “the food is smashing and the staff are good cooks”. Another client said the food was “always good”. Briar House DS0000025493.V309700.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The health and personal care needs of the clients were being well met with regular attendance for health care checks as needed. EVIDENCE: Since the last inspection, a new male support worker had been recruited which meant the team was more balanced in respect of gender. The male client said he liked his company and enjoyed going to the pub with him and playing pool. All 3 clients were able to express their individual needs and wishes. Two people said they chose what to wear, were supported to shop for clothes, had choices in what to eat and at weekends could stay in bed later in the mornings. Staff gave each person the individual support they needed, dependent upon the person’s individual abilities. When asked about bathing arrangements one client said “I have a bath every day” and another said “I can have a bath when I want”. All but one of the staff had worked with the clients for many years and knew each person’s preferred daily routines. All 3 clients were registered with local G.Ps. Care plan files had a section that recorded when visits had been made to health care professionals. The files Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 14 showed that annual health care checks, flu injections, G.P. optician and podiatry visits were undertaken as needed. Staff supported clients to attend appointments at surgeries or hospitals. From discussion with staff, it was evident that clients health care needs were closely monitored with referrals being made to appropriate professionals as necessary such as dieticians, psychiatrist etc. When any problems were identified either emotional or physical, the staff were knowledgeable about whom to seek help and advice from. Since the last inspection, the deputy manager had undertaken a half days mental health training session as well as attending training on behaviour management. The pharmacy inspector had made a visit to the home on 3 February 2006 and following the inspection, a report had been sent to the manager. The report evidenced the medication system to be safe but the requirement made for the medication policy and procedures to be reviewed to include homely remedies and self medication had not been done. Neither had the recommendation for clients to sign “Consent to Medication” forms been implemented. These areas were discussed with the manager, by telephone, following the inspection and must now be addressed as a priority. The three support workers who had worked at the home for many years had all received medication training. If the newest worker is to be responsible for the dispensing of medication, he must also attend such training. Briar House DS0000025493.V309700.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. Clients were confident their views were listened to and acted upon and procedures, together with staff training ensured they were protected from abuse, neglect or self-harm. EVIDENCE: A complaints procedure was in place and copies had been given to each client. These were seen in the back of their care plan files. Two of the people spoken to said they would be able to speak to any of the staff if they had any problems. One person identified one staff member whom she would always go to with any worries. At the last inspection, a complaints book was seen which did not contain any entries. On this visit, the book was missing and the deputy manager said it had probably been misplaced by one of the clients. She said if the book was not found she would replace it. She did however, confirm that no complaints had been made by any of the clients. The Commission for Social Care Inspection had not received any complaints about the home over the last 12 months. The home had a copy of the Rochdale Inter Agency Procedure for the Protection of Vulnerable Adults (POVA). The 3 long-standing support workers had done the Rochdale MBC POVA training, two having done it in February 2006. The deputy manager said the most recently recruited staff would be nominated for the next available course. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 16 An adult protection investigation had taken place since the last inspection. The investigation was thoroughly conducted in line with the home’s policies/procedures and all relevant agencies had been kept updated throughout the investigation and been notified of the outcome. In conclusion, all parties were satisfied that no further action needed to be taken. Staff meeting minutes showed that issues arising had been fully discussed with the team. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to this service. The home was clean, safe and well maintained affording clients a comfortable place to live. EVIDENCE: The house was located just outside Heywood town centre and on a local bus route. The home enabled each person to have their own large bedroom and the living accommodation was roomy with 2 lounges and a large dining/kitchen being provided. One of the clients showed the inspector her room, which she was clearly very proud of. She had personalised it with ornaments and dolls and had plenty of drawer and hanging space for her clothes. Another client said “I have my own chair and television in my room which I love”. A brief walk around the home, identified it was clean, hygienic and in good decorative order throughout. At the last inspection, it was identified that a split in the kitchen flooring could be unsafe for clients. This had been made safe by strong tape being affixed to the floor. The manager said the flooring would be replaced when a new kitchen was fitted but did not have a time scale in mind. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 18 The pre-inspection questionnaire indicated that policies/procedures were in place with regard to the control of infection. Disposable gloves and aprons were available and staff wore disposable aprons when preparing and serving food. An Environmental Health visit had taken place on 8 December 2005. The report was positive with only two minor areas being identified for improvement. These had been done. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 19 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, 34, 35 & 36 Quality in this outcome area is adequate. This judgment has been made using available evidence including a visit to this service. The small staff team were providing consistently good support and meeting the needs of the clients but poor recruitment practice could result in clients being placed at risk. EVIDENCE: The home was being staffed to meet the identified needs of the clients, as agreed with the Social Services Department who were funding the clients’ placements. The rotas were written to take account of what individual clients were doing during the evening or at weekends. On the evening of the inspection, the deputy manager and a support worker were on duty so they could undertake planned activities with the clients. The staff team was small with only a manager, deputy and 3 support workers being employed. The deputy manager provided sleep-in night time cover. Since the last inspection, there had only been one staff change and this low turnover had enabled the clients to develop trusting relationships with the staff team. The deputy manager had attained an NVQ level 3 qualification and 1 staff had achieved NVQ level 2. From checking the personnel file of the most recently Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 20 recruited worker, who had been in post since July 2006, it was noted they had not undertaken either TOPSS, Learning Disability Award Framework (LDAF) or “Skills for Care” induction training. The only training undertaken since starting work was food hygiene, which had taken place in October 2006. All new staff must receive relevant induction training to ensure they work safely and are able to meet the needs of the clients whom they are supporting. It was identified at the last inspection, that staff were not receiving a minimum of 5 training days, pro rata, each year. Whilst this had not been fully achieved, more staff training had been provided, especially for the deputy manager. She had attended various training courses, which included mental health, supervision, vulnerable adults, managing aggression and health and safety. The two other long-term staff had over the last year done protection training and behaviour management. Staff who had worked at the home for several years had all undertaken the mandatory health and safety training such as first aid, food hygiene, fire, infection control and moving/handling. It was however, noted that not all mandatory training had been kept updated and the manager must now undertake a training audit and ensure that all such training is updated as needed. The most recently recruited support worker had only done food hygiene training and action must now be taken to ensure the worker is booked on all other relevant courses. Since the last inspection, the owner/manager had purchased some training videos, which were to be used to provide refresher mandatory training. These included infection control, medication and adult protection and following the training, questionnaires accompanying the training packs were to be completed. The home did not have a recruitment/selection policy in place and this was evidenced at the last inspection. The file for the most recently recruited support worker was checked. The file was incomplete and poor recruitment practice evidenced. The applicant had failed to fully complete an application form. There were no references given or held on file and no previous employment history recorded. A Criminal Record Bureau reference number had been recorded on the file, but the date of receipt of the check and whether it was clear had not been recorded. Evidence of receipt of a Pova First check was seen. A telephone call to the home owner/manager ascertained she had previously known the worker from their previous employment and felt the person was honest and trustworthy. She said she had received two verbal references, but no recordings of such references were on the file. She said she had since obtained written references, which were held with the CRB check at her other home and that she would fax them to the CSCI office. These were faxed and were satisfactory. However, both references were completed by the owner and manager of the same home, which was unsatisfactory. In future separate references should be obtained. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 21 Irrespective of prior knowledge, in order to ensure vulnerable clients are fully protected, the manager must ensure all applicants fully complete application forms, give the names of 2 referees (one to be the most recent employer) and send for both references. CRB details should also document when the CRB was received and whether it was satisfactory. Since the last inspection, the deputy manager had attended a supervision training course but she said she still did not feel fully equipped to undertake this task. The level of one to one supervision sessions undertaken since the last inspection in December 2005 was low with only two staff having been supervised in January of this year. The most recently recruited staff member, who had commenced in July 2006, had not received any formal supervision. Due to the small nature of the team, informal on the job supervision was ongoing as both the manager and deputy worked with the staff on a day to day basis and were able to observe care practice. Team meetings had also been held on a regular basis and minutes seen evidenced that 5 had been held this year. The manager should now address this shortfall in supervision and ensure that all staff receive regular one to one meetings which she should undertake as part of her managerial role. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 22 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 & 42 Quality in this outcome area was good. This judgment has been made using available evidence including a visit to this service. Some management shortfalls were identified but in the main, the home was well managed with good outcomes being achieved for the clients who lived there. EVIDENCE: The manager, who was a trained nurse, but had not practiced for a number of years, was also the registered provider. She had kept abreast of care practice by reading journals and attending courses. The manager usually worked at the home from 09.00 until 13.00 Monday to Friday and her hours were recorded on the rota. The staff said she was usually there between these hours. She was not at the home during the inspection, which took place at 16.00 but was spoken to by telephone following the visit. It was identified at the last inspection in December 2005, that as she was nearing retirement she did not wish to undertake a formal management qualification. In light of CSCI guidance, this is acceptable in the short-term providing the home is well Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 23 managed and suitable arrangements are made for the future. A competent, well-trained deputy manager who had known all 3 clients for many years, assisted in the running of the home. The small team of support staff knew the clients well and gave them appropriate guidance and support. Feedback from clients about their satisfaction with how they were supported was an ongoing process done in an informal, friendly way. Occasionally, when specific issues needed to be discussed, more formal resident meetings were held. The last one had taken place in March 2006 when the topic of summer holidays was raised. In addition pictorial quality assurance questionnaires were completed with smiley and unhappy faces being used as required. The deputy manager had gone through the questionnaires on a very regular basis with each of the clients, using the original questionnaire and indicating on the reverse of the form their updated opinions. From speaking to the residents, it was clear they were happy and settled at Briar House. In the past, feedback questionnaires had been circulated to day centre staff but these had not been obtained for some considerable time. The home should also consider obtaining the views of other visiting professionals, e.g. care managers, G.P.’s etc. None of the clients’ families had regular contact with the home. Since the last inspection, the deputy manager had completed a four day health and safety course at the local college which had raised her awareness in a number of areas. Information from the pre-inspection questionnaire showed that all the necessary maintenance checks had been undertaken. Random samples of records relating to the electrical appliances, environmental health visit and fire appliances were all satisfactory. The home had a good record of meeting health and safety requirements and no safety issues were identified on this inspection. Policies and procedures were being followed although the medication policy needed to be updated and a recruitment and selection policy was in need of writing and implementing. No accidents had been recorded in the accident book. This book was not the newly formatted type that complied with the Data Protection Act. The home should obtain the up to date copy as highlighted at the last inspection. Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 24 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 X 3 X X 3 X Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? YES 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 YA20 Regulation 13 Requirement The registered provider must ensure that the medication policies/procedures are reviewed to include homely remedies and self-medication. (Previous timescale of 10/03/06 not met). The registered provider must ensure that ‘Skills for Care’ or the Learning Disability Award Framework induction and foundation training be provided for new staff. (Previous timescale of 31/03/06 not met). The registered provider must ensure that new staff do not start work until a full employment history together with a satisfactory explanation of any gaps in employment and 2 satisfactory references have been obtained. The registered provider must implement a recruitment and selection policy/procedure to ensure the home recruits new staff in line with up to date legislation contained in the updated Care Homes DS0000025493.V309700.R01.S.doc Timescale for action 31/12/06 2. YA32 18 28/02/07 3. YA34 19 30/11/06 4. YA34 19 31/12/06 Briar House Version 5.2 Page 26 Regulations. 5. YA34 19 The registered provider must ensure that details of CRB checks held on the individuals file contain reference number, date of receipt and whether or not the check was satisfactory. The registered provider must undertake a staff training audit to identify which staff need to undertaken mandatory training and which staff need refresher training. Where shortfalls are identified, training courses must be arranged. 30/11/06 6. YA35 18 30/12/06 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. Refer to Standard YA6 Good Practice Recommendations Care plans should be further developed to include exactly what personal care assistance they need and preferred daily routines should as rising/retiring etc. should be recorded. Consent to staff administration of medication should be recorded within individual care plan files. If the most recently recruited support worker is to be responsible for administering medication, then training should be undertaken. The provider/manager should ensure that all staff receive regular structured supervision which should address training needs. 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 clients and the service. A newly formatted accident book should be provided. 2. 3. 4. 5. 6. 7. YA20 YA20 YA36 YA37 YA39 YA42 Briar House DS0000025493.V309700.R01.S.doc Version 5.2 Page 27 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.V309700.R01.S.doc Version 5.2 Page 28 - 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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