CARE HOME ADULTS 18-65
Briarways 30 Silverlea Gardens Horley Surrey RH6 0BB Lead Inspector
Lisa Johnson Unannounced 16th May 2005 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 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 Stationary 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. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION
Name of service Braiarways Address 30 Silverlea Gardens Horley Surrey RH6 0BB 01293 431310 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Ashcroft Care Services Ms Jennie Whitfield Care Home 4 Category(ies) of LD Learning Disability (4) registration, with number of places Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 18-65 years. 2. The gender of those to be accommodated will be: male. Date of last inspection 16 September 2004 Brief Description of the Service: Briarways is a detached house in a residential road within, Horley Surrey. thee home is accomodated on two floors. The home accomodates four Service users who have Learning disabilities. Service users in the home have their own single bedrooms, which have a washbasin and are and are dcorated to the individual tastes of the Service Users.The ground floor cosists of a communal kitchen and dining room, lounge utility room and one bedroom. The home has a large enclosed garden and there is a small area at the front of the house which is available for parking. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the homes first inspection for the year 2005/2006. and was an unannounced visit, which meant that staff and residents were not aware that it was due to happen. Two inspectors carried out the inspection arriving at 12.10 pm and leaving at 4.10pm. Inspectors spent the first part of the inspection touring the premises and talking to the manager which also included looking at some of the documentation, which is held in the home. The inspectors looked at the homes statement of purpose, medication records, service users assessments, care plans and risk assessments. The inspectors also looked at the staff duty rota, personnel files and training records The inspectors then spoke to the service users who had returned to the home for lunch from activities. Service Users were asked what it was like to live at Briarways. The inspectors then spoke to staff that work in the home to gain their views The Inspectors would like to thank the staff and service users for their time and assistance in carrying out this inspection, and for the hospitality What the service does well:
The Service has a motivated manager and the staff team have a good knowledge of the service users and their needs. Although there is some environmental work that needs to be undertaken there was a very homely feel In Briarways day-to-day choices were observed to be promoted in the home such as choices of activities and meals. The home provides a good range of activities and leisure pursuits and has recently installed a summerhouse that is being utilized as a sensory room. An active key worker system is in place and staff interaction with service users was observed to be positive giving evidence of good relationships This was confirmed by two service users in he house who said they were happy and that staff will listen and help with any problems,. One of the service users spoken to communicates using gestures and makaton sign language and used the sign “Thumbs Up” for happy. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 6 What has improved since the last inspection? What they could do better:
The cupboard for storing hazardous substances was found unlocked and some bath cleaner was found accessible l in the upstairs bathroom. There were some gaps in the recording of fridge temperatures, which should be taken every day. At present all the files for the service users are very large and there is a lot of different documents which need updating. Assessments need updating; care plans need putting together, which should also include detailed risk assessments. There is still some maintenance work that needs to be carried out in the home. The upstairs bathroom urgently requires replacing; this is still outstanding from the last visit. Inspectors were concerned about the security and general condition of the door and window of the downstairs bedroom. The area at the front of the house needs reviewing to look at the storage area for the refuse bins. A v requirement has been made that the home submits a risk plan in light of the safety issues while the maintenance work is gong on. It has also been recommended that extra seating be obtained fort the sitting room as this did not look adequate when everybody could be in the room at the time. Although the manager has attempted to complete some of the staff files but the organisation has not made all the relevant documents available. The home must put together a written risk plan in relation to there being one member of night staff on duty. Although each service user in the home has their own copy of the service users guide a central copy should be maintained and a requirement was made that the statement of purpose needs more detail about the service it is able to
Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 7 offer. An updated copy of the surrey multi agency policy should be made available. Medications have been overstocked and some of these medications need returning to the pharmacy. A list of all homely medications in the home should be made available and the use of keeping paracetamol as stock should be ceased. All service users should have their owned labelled supply. Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 8 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 Standards Statutory Requirements Identified During the Inspection Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 9 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 standard(s) 1, 3 & 5 The homes statement of purpose is adequate, but needs to contain more indepth information as to what the home provides. EVIDENCE: The home has reviewed its statement of purpose which describes the structure of the staff team, their qualifications, the range of the service users for whom it is intended that accomodtion should be provided. The complaint policy is documented in the service user guide. The home does state that that social activities and leisure activities are provided but these need to be described in more detail to provide more information as. to how these will be provided. Details of any treatments should be stated and how these are monitored and supervised. Although there have been no recent admissions to the home a more detailed Statement of Purpose would assist any future prospective service users a lot more information in making an informed choice as to whether the home would be a suitable place to live. A service User guide is in place and the manager informed the inspectors that service users maintain their own copy. A requirement was made that a copy is maintained centrally as well. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 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 standard(s) 6. 7, 8. 9 & 10 The home encourages the service users to be independent and to be able to make choices. howeverstructured care plans need to be formulated EVIDENCE: Evidence was seen that service users were encouraged to be as independent as possible and by giving service users choices about meals and activities to increase their participation. One member of staff stated that if a service user would like something to eat and it is not available in the home at that time then they will go out to the shops. The staff team in the home are very motivated about supporting service users to attend activities. One staff member said at weekends spontaneous activities as well as planned ones take place and service users are given the choice whether hey would like to attend or not. The staff team have a good knowledge of the needs of the service users but the assessments of each service user must be updated. There is a lot of information available in large folders, but no structured written care plans were in place. Risk plans have been implemented but also need updating. A requirement has been made that all the information from the assessment
Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 11 should be drawn up into one plan. Service user files were found to be kept secure in cabinets in the office. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 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 standard(s) 11, 12, 13, 14, 15, 16, 17 The home is able to demonstrate that residents are encouraged and supported to live as fulfilling life as possible. EVIDENCE: Briar ways supports service users to take part in a range of activities and have a detailed timetable in place. On the day of the inspection all of the Service users were out undertaking activities returning at lunchtime. One of the service Users who communicates by using gestures and makaton sign language signed the symbol for horse riding he showed the inspectors photographs of himself participating in riding and it was clearly seen that he enjoys this activity. Some of the service users attend classes at college and participate in cookery. Trips to the seaside, and to local amenities take place. Service users are offered choices with regard to meals and alternatives are available. One service user said “I can have a sandwich for lunch if I don’t like what is being served on the menu”. The home is in the process of planning holidays for service users and one service user said “I am going to Coombe Haven in Hastings for my holiday”. Some of the service users maintain contact with their families.
Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 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 standard(s) 18, 19 & 20 The staff have a good understanding of the Service users support needs, but a structured care plan needs to be put in place. The storage and stock control of medication needs reviewing. EVIDENCE: On sampling service user files a lot of information was evident in them. Assessments, risk plans and guidelines were found to be out of date and difficult to read. There was no care plans in place. The care plan should be structured to include all the identified needs from the assessment and should refer to any guidelines. The plan should include any identified risks. A requirement has been made that all the service users assessments, care plans and risk assessments are updated and only updated and relevant information should be kept in the file. Medication records were examined and were satisfactory; as required medication protocols were in place and the staff list of staff of who is trained to administer medication is up to date. However the medication cupboard is an insufficient size, the manager stated that she is in the process of ordering a new one. The medicines in the cupboard were checked and due to the size of the cupboard, internal prescriptions were found to be stored next to external applications.. Paracetamol was labelled as being stock; there was no individual supply with a label with the service users name.on.There was some external medication that was out of date and excessive supplies of some medication that needs returning to the chemist. A
Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 14 requirement is made that a homely remedies list is available for each service user and that it is agreed and signed by the G.P. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 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 standard(s) 22&23 The home has a satisfactory complaint procedure with some evidence that service users feel that their views are listened to. EVIDENCE: The homes complaint policy is available and the home maintains a complaints register. A copy of the surrey Protection of Vulnerable Adults policy is available but a requirement has been made that the manager obtains the updated version. Evidence was seen in staff training records that they attend Adult protection training. The inspector’s spoke to two members of staff who were very clear as to what they should do if they saw any abuse taking place and that they would report it. The inspectors spoke to one service user who said he was happy living at Briarways; he stated that he felt he could go to the staff and that they would listen if he had any problems. Another service user in the home who communicates by using makaton sign language stated that he was happy by using the “ Thumbs Up” sign for happy. Positive interaction between staff and service users was observed during this inspection. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 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 standard(s) 24,25,26,28,29 & 30 The service portrays a homely atmosphere but the standard of some of the décor and facilities needs improvement. EVIDENCE: The home was found to be in a clean condition. One of the service users was happy to show the inspectors his room, which was individually decorated to his taste. One service showed us photographs of places he had visited and friends that he has and he had a wide range of personal belongings. The kitchen is in the process of being refurbished and the home is awaiting the installation of their new bathroom, which is an outstanding requirement from the last inspection. The home has a large pleasant garden, which is well maintained. It was pleasing to see that a summerhouse has been erected which has been converted in to a sensory room for the service users which they all enjoy. It was observed that the window and door outside the lower bedroom was not shutting adequately which is a security concern and in need of maintenance and repair. The garden area in front of he house needs reviewing to make good the area for storing the refuse bins.
Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 17 It has been recommended that the home purchase some more chairs in the sitting room as it was felt that at present the chairs available are inadequate if everybody was in the sitting room at the same time. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 36 The manager is supported well by staff in the home. Emphasis has been placed on the development of the staff team EVIDENCE: A new manager is in place at the home and it was evident that emphasis is being placed on developing the staff team. Regular supervision is taking place and records were sampled. Training records for staff was examined and it is clear that mandatory training is occurring for fire, moving and handling, food hygiene and health and safety. Staff are being booked to attend the surrey multiagency training for Adult Protection. The manager and deputy hold National Vocational qualifications in care and the manager stated that senior staff who take charge of shifts are completing a training package on shift leading competencies and a copy of this was made available to the inspectors. The duty rota was examined and staffing levels were found to be adequate. There are three staff on in the morning and three in the afternoon, the manager works one supernummary day every week. At nighttime there is only one staff available with an on call facility i in place if any help is required. Although staff didn’t have any concerns around this and have never experienced any problems a requirement has been made that a risk assessment is implemented. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 19 Staff files were examined and references are still not available. The manager has asked the organisations personnel department for this information but these are still not on file and a further requirement is being made Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 40, 42 &43 The manager has a good understanding of the areas, which need improving; health and safety procedures need to be adhered to EVIDENCE: The manager of the home holds national vocational qualifications in care. and has past managerial experience. The staff in the home stated that they receive regular supervision and that their developmental needs are discussed. From discussion with staff there is positive and open relationships. From discussion with the manager links are being maintained with service users families, policies and procedures are in place and there is evidence that these are communicated to the staff team. Service user records are kept secure in locked cabinets in the office. The manager maintains records of staff training and has undertaken all mandatory training including medication and all staff taking charge of shifts are completing training.
Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 21 Records of fridge temperatures are in place but it was found that there were some gaps in the daily records and requirement has been made that fridge temperatures are recorded daily. Appropriate storage of food was in place. However the cupboard in the kitchen containing the cleaning liquids was found unlocked and some bath cleaning liquid was found in the bathroom. It is required that all hazardous items are kept locked and secure at all times. .. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 x 2 x 3 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
Briarways Score 1 3 3 2 3 Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 3 2 3 3 3 Standard No
H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Score
Version 1.20 Page 22 LIFESTYLES Standard No 11 12 13 14 15 16 17 Score 3 3 3 3 3 3 3 31 32 33 34 35 36 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 2 2 3 Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 23 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. 2. 3. 4. Standard YA 1 YA 1 YA 3 YA 6 Regulation 4(1) (c ) 5(1)(a) 14(1)(a) 15 (1) Requirement The statement of purpose must be more detailed in describing as to what the home provides A copy of the service user guide must be held centrally Assssments for all service users must be be updated A structured care plan must be put in place for all sevice users based on he outcomes of an assessment All service users risk assessments must be updated and are included in the care plan. A medicine cabinet imust be acquired so that internal and extenal medications can be stored separately.All expired medication is to be sent back to the pharmacy. A list of all homely remedy mediication used in the home must be made available and all paracetamol tablets are to be labelled with the name of he service user. The window and door in the downstairs bedroom requires maintence and making secure The garden area in the front of Timescale for action 2months 16/7/05 2months 16/7/05 2months 16/07/05 3months 16/08/05 3months 16/08/05 2 weeks 30/05/05 5. YA 9 13(4)(b) 6. YA 20 13(2) 7. YA 20 13(2) 3 weeks o6/06/05 8. 9. YA 24 YA 29 23(2)(b) 23(2)(b) 1month 16/06/05 2months
Page 24 Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 the house requires maintence 10. YA 24 23(2)(b) The bathroom must be refurbished. (previous requirement of 16/12/04 not met) A risk asseessment must be imlemented to ensure the safety of service users while the refurbisment is being undertakenl a review on the number of night staff must take place Copies of two referencs must be maintained on all staff files(previous requirement of 16/12/04 not met) Fridge temperatures must to be recorded daily All COSHH materials must be stored and locked securely 16/07/05 4.5months 30/09/05 2 weeks 30/05/05 11. YA 42 13 (4)(a) 12. 13. YA 33 YA 34 13(4)(c ) 17(2)(sch edule4) 13(4)(c ) 13(4)(c ) 2months 16/06/05 1 month 16/06/05 immediate 16/5/05 immediate 16/5/05 14. 15. YA 42 YA 42 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 24 Good Practice Recommendations The home considers acquiring some extra chairs for the sitting room. Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 25 Commission for Social Care Inspection 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 Briarways H58-H09 s13577 Briarways v221151 160505 Stage 4.doc Version 1.20 Page 26 - 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!
