Inspection on 17/11/05 for Briarways

This inspection was carried out on 17th November 2005.

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 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

Briarways 26/01/09

Briarways 29/01/07

Briarways 16/05/05

Briarways 16/09/04

Briarways 20/05/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

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33 St John`s Church Road

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

CARE HOME ADULTS 18-65 Briarways Briarways 30 Silverlea Gardens Horley Surrey RH6 0BB Lead Inspector Peter Benthom Announced Inspection 17th November 2005 10:00 Briarways DS0000013577.V258926.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 Briarways DS0000013577.V258926.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. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Briarways Address Briarways 30 Silverlea Gardens Horley Surrey RH6 0BB 01293 431310 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) Ashcroft Care Services Ltd Ms Jennie Whitfield Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The age/age range of the persons to be accommodated will be: 18-65 YEARS The gender of those accommodated will be: MALE Date of last inspection 16th May 2005 Brief Description of the Service: Briarways is a detached house in a residential road in Horley Surrey. The home accommodates four Service users with learning disabilities. Service users have their own single bedrooms. The ground floor consists of a communal kitchen and dining room, lounge and utility room. One service user is accommodated on the ground floor. The home has a large enclosed garden and there is a small parking area at the front of the building. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the second of the year 2005/6 and was conducted by an inspector from CSCI. The manager is awaiting the final part of the registration process and was present for the inspection. Two members of staff were on duty and two of the three Service Users in the home were spoken with. What the service does well: 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. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 6 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 Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 7 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): 1,2,3,4 and 5 Service users are admitted only following a full assessment undertaken by people trained to do so. The manager was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The Statement of Purpose was seen to be in place and contained all information required in Schedule 1 of the Care Home Regulations 2001. The Service User was seen to be appropriate in its content, but requires some updating of relevant information and a copy to be held centrally. The initial assessment was used to form the basis of the care and the support plan, which identified the actions that carers should follow to assist an individual living at the home. Care plans were noted as including comprehensive assessments of service users prior to admission. Written contracts between the home and service user were seen. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 8 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, 8, 9 and 10 The systems for Service User consultation are good with evidence that their views are sought and acted upon. EVIDENCE: Extensive care plans have been drawn up, with the help of the service user wherever possible and relatives/representatives. Care plans were well documented and highlighted all areas of care needs for each service user. All care plans showed evidence of regular reviews. Risk assessments were in place where appropriate. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 9 During the inspection it was evident that staff respect the Service Users’ right to make decisions. Evidence was provided with examples of the Service Users’ opportunities to participate in the day-to-day running of the home e.g. helping with food shopping, assisting with meal preparation. Staff enabled Service Users to take responsible risks - wherever possible – and this was clearly documented in each individual care plan. Risk assessments were being carried out as/when necessary and existing ones regularly updated. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 10 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): 11, 12, 13, 14, 15, 16 and 17 Links with relatives, friends and the local community are good. These links support and enrich Service Users social and educational opportunities EVIDENCE: Examination of the home’s records confirmed a high degree of personal empowerment and choices in services users daily lives. They were encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. Service Users attend various day centre and adult education activities. A different variety of community-based activities are available. The activities programme was individualised in accordance with Service Users wishes and made appropriate use of college courses, community amenities and facilities. One service user has requested to move to another Ashcroft service and as such plans are being made to assist the process in as full and inclusive way as possible. All Service Users go out into the local community on a regular basis supported by members of care staff. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 11 The manager stated that Service Users are going out on excursions and holidays, risk assessments were seen as part of the daily activity programme in the home. Service Users had access to a range of appropriate leisure opportunities in accordance with individual preferences. They were encouraged to pursue individual interests and hobbies. Staff attempt to maintain links with Service Users’ families. Any visitors could be entertained either in the service user’s own room or in the garden. Friends are invited to visit. The home has maintained some good family links. There are no restrictions in terms of visiting times. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 12 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 and 20 The healthcare needs of Service Users are well met with evidence of good consultation with other professionals taking place on a regular basis. EVIDENCE: The home had adopted a key worker system and each individual service user had a key worker who knew them and their family well. The key worker with support from the management team was responsible for developing and reviewing the service users’ care plan. Staff ensured that specialist support was provided where necessary. All service users are registered with the local GP. A local surgery provides health care to the service users, which includes health checks, continent assessment and some staff training. The arrangements for all aspects of administration of medication appeared to be satisfactory. Medicines for each service user were recorded and stored accordingly in line with the RPS (Royal Pharmaceutical Society) guidelines. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The home has a satisfactory complaints system that is made available to all Service Users and staff. 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 to all staff. The complaint procedure was compliant with statutory requirements. Complaint forms were available for recording complaints. Records demonstrated there had been no formal complaint received by the home or the regulator within the last twelve months. The organisation had its own adult protection policy The subject of abuse was addressed within the staff induction programme. Up to date training in the Protection of Vulnerable Adults will be talking place on an ongoing basis. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 14 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, 27, 28, 29 and 30 The standard of décor and equipment in this home is very good with evidence of improvement through continual maintenance and refurbishment. EVIDENCE: Overall the home was in good condition; appropriately decorated, well maintained and furnished to a high standard. The secluded garden is particularly attractive and of a large size, stocked with garden furniture. There were sufficient bathrooms and toilets to meet the national minimum standard. The communal areas in the home were considered safe and accessible for the Service Users. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 15 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, 33, 34, 35 and 36 The staff have a good understanding of the needs of the Service Users in this home. This is evident from the positive relationships that have been formed between the staff and the Service Users. EVIDENCE: Staff spoken to at the day of the inspection had a good understanding of their job descriptions and their responsibilities and they were able to identify the roles of other members of staff in the hierarchy. Communication between staff was good. At the day of the inspection personnel files were seen and considered to be accurate. However photographs of staff need to be included on all personnel files. Please see requirements on page 20 of this report. All documents required by Schedule 2 of the Care Homes Regulations 2001 were available in individual files. Staff meetings are in place and are organised monthly. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 16 80 of staff have NVQ Level 2 and four members of staff hold current first aid certificates. The manager is involved in all aspects of staff recruitment and policies and procedures were in place for recruitment and employment. Records of good practice were seen in the Home. The recruitment procedure was observed to be robust. Briarways DS0000013577.V258926.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): 37, 38, 39, 40, 41 and 42 The manager is well supported by the senior staff team and by the organisation in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The manager has almost completed NVQ Level 4 and has had extensive relevant experience. She is employed full time and works alongside other staff on the rota. There is good leadership and consistent direction to staff in this home to ensure that Service Users receive consistent quality care. The manager is fully aware of the needs of the Service Users in the home and as such is able to communicate this to staff through regular staff meetings and individual supervision sessions. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 18 The manager illustrates a full commitment to the home and its Service Users. The frequency of staff meetings and informal supervision was indicative of an open and supportive atmosphere. Regulations 26 (Monthly visits by the proprietor) are undertaken and evidence was seen of their occurrence. Relevant policies and procedures were in place. Systems existed to demonstrate these had been communicated to staff. Also those of relevance to service users had been shared with them. Records examined included; care plans, medication procedures, staff meeting minutes, risk assessment policies and service user activity programmes. They were seen to be in good order. There were policies and procedures in place for the health, safety and welfare of service users and staff. Detailed policies and procedures were in place in relation to safe working practices. Staff were trained in First Aid, Food Hygiene and other aspects of Health and Safety. Briarways DS0000013577.V258926.R01.S.doc Version 5.0 Page 19 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 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Briarways Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000013577.V258926.R01.S.doc Version 5.0 Page 20 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 YA1 Regulation 5(1)(a – f) Requirement Timescale for action 31/12/05 2. YA34 A copy of the service user guide must be held centrally and information contained must be updated. 17(2)(schedule4) Copies of two references application forms and evidence of a CRB check must be maintained on all staff files. 31/12/05 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 YA41 Good Practice Recommendations It is recommended that out of date information contained in care plans is archived. 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