CARE HOME ADULTS 18-65
Briarvale Care Home 158 Ashby Road West Shepshed Loughborough Leicestershire LE12 9EE Lead Inspector
Keith Charlton Unannounced Inspection 14th December 2005 04:00 Briarvale Care Home DS0000049403.V271406.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 Briarvale Care Home DS0000049403.V271406.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. Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Briarvale Care Home Address 158 Ashby Road West Shepshed Loughborough Leicestershire LE12 9EE 01509 829283 01509 829603 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) Mr Stephen Boggins Mr Malcolm Wood Ms Ruth Wardhaugh Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. To be able to admit one named person in category LD/PD (dual disability) as agreed with the previous registration authority. Date of last inspection Brief Description of the Service: Briarvale is registered to provide care for 10 people with learning disabilities. The accommodation consists of 10 single bedrooms. There has been an extension, which removed the only double bedroom and created 4 new bedrooms, all with en suite facilities. A new service users lounge was also created on the ground floor. It is pleasantly furnished and decorated to a generally good standard. There is a large garden and patio area to the rear where service users can sit out. The home is situated close to Shepshed town centre and local shops are within easy reach. Most service users attend local day centres. Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service user and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting two service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. There are only a small number of service users that can communicate their views. This was an unannounced Inspection. The Registered Manager was on duty to assist with the inspection process. Two other staff were also on duty. Planning for the Inspection included assessing notifications of significant events sent to the Commission for Social Care Inspection by the home. There have been no complaints received regarding the home in the past year. The Inspections took place between 16.05 and 18.40 and included a tour of the building, inspection of records and direct and indirect observation of care practices. The Inspector spoke with three residents, two members of staff and the Registered Manager. What the service does well:
Care Plans are very comprehensive and detailed to assist staff to deliver care that fits individual service users care needs. The Registered Manager has ordered aids for a service user who has an acute condition and ensured that staff have been trained to operate the hoist. The service users spoken to indicated that they liked living in the home and that staff were friendly. A choice of foods is always available to service users and they are asked what they would like. The Registered Manager has devised a user-friendly questionnaire to assist with ascertaining views about living in the home. Staff were again found to be friendly and helpful in their dealings with service users. Bedrooms are personalised and homely and organised to service users styles of living. One service user proudly showed the inspector her bedroom with all her possessions.
Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 6 Facilities are kept in a clean and tidy condition and decor is kept to a high standard. The Registered Manager keeps a monthly maintenance list so that essential jobs are carried out. The Registered Manager arranges service users meetings to provide information about services and asks their views about them. Relatives can also attend these meetings to see what is going on in the service. The Registered Manager continues to be proactive in planning for staff training and asking for suggestions on how to improve the service. Very detailed staff meeting notes are kept to alert staff to care needs and staff practice. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Briarvale Care Home DS0000049403.V271406.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 Briarvale Care Home DS0000049403.V271406.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): National Standard 2 was inspected at the last inspection. Please refer to this Inspection Report. EVIDENCE: N/A Briarvale Care Home DS0000049403.V271406.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): 6,9 The individual needs and choices of people living in the home are well met. EVIDENCE: The inspector case tracked two care records, which clearly demonstrated that their changing needs are being monitored and supported whilst living at the home. Records, observations and discussions with clients demonstrate that clients make decisions about their lives and have independent life styles. Staff said service users can make decisions about their own lives wherever possible e.g. what time to get up and go to bed, to clean their own bedrooms, to help out in domestic chores if they wish, one service user is able to have a bath independently, the Registered Manager looks towards service users going out unaccompanied if possible etc. All service users require assistance with their finances and medication. Individual plans contained details of the circumstances in which service users’ rights to make particular decisions may have to be limited, e.g. the need to accompany on trips outside because of the lack of road skills. Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 10 Briarvale Care Home DS0000049403.V271406.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): 12,16 Clients living at the home have a good lifestyle. EVIDENCE: Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 12 Service users spoken to said they liked going out. Service users were due to go to a disco on the evening of the inspection and had been to a local pub for their Christmas meal in the past week. Records showed that clients have been on trips and are asked where they want to go on holiday. Regular trips are planned in the future. Clients are supported in helping in the kitchen with supervision as necessary. Staff said that service users use a range of community facilities including local shops, pubs, the park and leisure centre as well as attending specific groups for people with learning disabilities. The service users meeting notes in November 2005 showed that they were involved in planning for Christmas – what they wanted as a present, putting up the tree and decorations, making cards etc. Briarvale Care Home DS0000049403.V271406.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): 18,19 Clients receive good personal support with their physical and emotional health needs being well met. EVIDENCE: Through observation, discussion and records, it was demonstrated that clients receive support in the way they prefer and require it. Care Plans indicate all aspects of service users health care needs are covered – e.g. management of diabetes, dementia, personal care, monitoring weight, communication, social skills, work and play etc. The Registered Manager keeps a detailed record of clinical records, which clearly shows the medical interventions, received and needed by service users from nurses, GPs, dentists, chiropodists etc. Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Client’s views are listened to, and on the whole, acted upon. EVIDENCE: There is a residents meeting held once a month where all residents are invited to attend and share their views about the home. The clients spoken with during the inspection felt able to talk to staff, and felt that most issues were acted upon. One said ‘I don’t have any problems with staff – they listen to what I say’. A staff member on duty was asked about her understanding whistle blowing procedures, and she demonstrated a good understanding of them. Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Clients live in a homely and comfortable environment, and standards of hygiene are satisfactory. EVIDENCE: The inspector looked at the bedrooms of clients and the communal areas. Observations of the bedrooms demonstrated that clients décor in their bedrooms suit their needs and lifestyles, standards of cleanliness in the bedrooms were satisfactory. The Registered Manager said that one bedroom was to be decorated in early 2006 with the flooring replaced. The communal lounge/dining room areas have been decorated to a satisfactory standard and these areas were in a reasonable state of cleanliness. Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33,34 Service users benefit from a dedicated staff group. EVIDENCE: Staffing levels during the course of the inspection met the relevant minimum standards. There are generally three care staff on duty when service users are in the home. These are higher than normal as one service user needs have one to one care within the Home and two to one care when he goes out. There is a waking staff member of night staff on duty at night and two staff members on call. There is now a domestic worker, which means care staff, can concentrate more on care work. The Registered Manager tries to ensure that the use of Agency staff is kept to a minimum though believes that staff should not work excessive hours to prevent fatigue and stress. This practice is commended. A staff record was inspected and found to have all the necessary statutory checks. The staff member spoken to was enthusiastic about providing a good service to residents. Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 17 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): 42 Service users benefit from the proactive management of the home. EVIDENCE: The uncovered radiators in the lounge have now been dealt with and the Registered Manager is to arrange fitting of covers as assessed as needed for two further service users. The Registered Manager stated that it would be better, because of the high dependency needs of service users, not to evacuate service users from their bedrooms at night but would be safer to leave them in their bedrooms behind a fire protected door. This is to be agreed with the Fire Officer and incorporate within the fire risk assessment. Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 18 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 4 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Briarvale Care Home Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score X X X X X 3 X DS0000049403.V271406.R01.S.doc Version 5.0 Page 19 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. Standard Regulation Requirement Timescale for action 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 Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Briarvale Care Home DS0000049403.V271406.R01.S.doc Version 5.0 Page 21 - 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!
