Inspection on 29/01/07 for Briarways

This inspection was carried out on 29th January 2007.

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 17/11/05

Briarways 16/05/05

Briarways 16/09/04

Briarways 20/05/04

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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 Cathy Clarke Unannounced Inspection 29 January 2007 11:00 th Briarways DS0000013577.V324055.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 Briarways DS0000013577.V324055.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. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 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 Yvonne Susan Rowe Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Briarways DS0000013577.V324055.R01.S.doc Version 5.2 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 17th November 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. Charges for the service range from £1518 to £1851 per week. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit using the new ‘Inspecting for Better Lives’ (IBL) process. Regulation Inspector Cathy Clarke was assisted throughout the site visit by the shift leader and deputy manager who were representing the establishment. The IBL process involves a pre-inspection assessment of service information from a variety of sources. Initially helping to prioritise the order of inspections and identify areas that require more attention during the inspection process. Details from each source of enquiry are compiled in a new form of inspection record used by the Inspector throughout the inspection process. The inspection of Briarways took place over a period of 5 hrs during which samples of; care assessments, care plans, a tour of the premises and staff records were inspected. All of the key inspection standards for Younger Adults were assessed. One survey was received by the CSCI from a relative of a service user and comments have been included in this report. Charges for the service range from £1518 to £1851 per week. The inspector would like to extend thanks to the management and staff of Briarways for their assistance and hospitality during the inspection. What the service does well: What has improved since the last inspection? The service user guide is held centrally and is in each of the service users bedrooms. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 6 Recruitment files are held at the Ashcroft Care Services Head office and do contain copies of references and evidence of criminal record bureau checks. The service is going to further improve recruitment records stored in the home by producing a document containing all of the key recruitment information for each member of staff. Out of date records have now been archived as per the recommendation made during the last site visit. The home has been decorated since the last inspection and a new carpet has been fitted in the lounge. 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. The summary of this inspection report can be made available in other formats on request. Briarways DS0000013577.V324055.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 Briarways DS0000013577.V324055.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 1 and 2 were assessed. This judgement has been made using available evidence including a visit to this service. Appropriate information is available for prospective service users in order for them to make an informed choice about moving into the home. EVIDENCE: There has been one admission to the home since the last inspection. The service user has settled in well and there is evidence in the homes records to confirm that his health has improved since moving in. Admission records were complete and gave a good insight into the individual likes and dislikes of the service user. A service user guide is provided to all new service users and kept in their rooms. It is recommended that this be reviewed and updated to take account of the recent staff changes made within Ashcroft Care Services. One assessment record sampled did not identify the ethnicity of the service user. Please see recommendations section of this report. Briarways DS0000013577.V324055.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 6,7,and 9 were assessed. This judgement has been made using available evidence including a visit to this service. Service users individual plans of care provide information on their changing needs and how decisions are made to ensure that they are able to take part in a fulfilling life whilst assessing any risks. EVIDENCE: Each service user has a chart, which tracks their individual achievements. Staff assist service users where required ensuring that where possible they further promote their independence. Risk assessment for service users have been reviewed and updated. The primary healthcare checklist for service users must be reviewed and updated where indicated. One care plan review showed that the service user had been present throughout the review and appeared happy and content with life at Briarways. There are no advocates involved with service users as they all have family. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 12,13,15,16 and 17 were assessed. This judgement has been made using available evidence including a visit to this service. Service users take part in a number of individually assessed activities; have their rights respected and appropriate relationships with family are enjoyed. Meals are planned with the service users input and the health needs of service users are taken into account. EVIDENCE: Some of the service users had been out to the local equestrian centre in the morning and another informed the inspector that he is going to a farm on Friday in Horley, which he is looking forward to. There is a structured programme of activities taking into account the individual likes and dislikes of the service users. The inspector was informed that staff have been trying to get one of the service users enrolled on a music session. Holidays are being planned for this year with the service users taking an active part in the plans. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 11 Family can visit the home at any time and often come to take service users out or they may visit family members for a break. One parent has commented in a report held in the home that “staff are pleasant, courteous and pleased to see them, and that they paid interest in the parents relationship with their son”. Another relative of a service user has stated the following comments in his survey to CSCI: “I’m very happy with the care that my brother receives at Briarways”. “He has been happy and settled now for ten years, and I think the house makes a great effort to provide stimulation, activity and security”. There is a planned four weekly menu, which service users help to choose. It was noted that there are a variety of choices available and service users often like to eat out. The cultural needs of service users are reflected in the dietary choices. One of the service users loves fish fingers and these are always available. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 18,19 and 20 were assessed. This judgement has been made using available evidence including a visit to this service. Personal support and the needs of service users are provided to promote and ensure that the physical and emotional health needs of service users are met. Medication policies and procedures are in place to protect service users. EVIDENCE: During the site visit staff assisted service users with their personal care needs in the privacy of their room or the bathroom. Staff were seen to knock on doors and call out to service users before entering their rooms. Each service user has a star profile, which indicates the achievements that service users have made since their initial assessment. Shaded areas on the star show a pictorial record of the increase in achievement against each area of assessment. Regular health care reviews are undertaken with the appropriate health care professionals. Healthcare records must be updated as indicated. Records have been marked where this is to be undertaken. In particular one record Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 13 referred to one of the service users having an identified weight problem but did not record the most recent weight of the service user concerned. Staff were able to comment on the progress of this service users weight and therefore a recommendation has been made with regard to maintaining accurate and up to date records. Medication protocols are in place for service users who require rectal diazepam. This is in the service users records. There is a weekly medication stock-tracking audit undertaken. Medication is kept in a locked cabinet in the office and records and medications were checked as correct at the time of the visit. It is recommended that the home request an audit visit from the local pharmacy that provides their medication service to ensure that they are compliant with current best practice. Please see recommendations section of this report. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 22 and 23 were assessed. This judgement has been made using available evidence including a visit to this service. The policies and procedures of the home provide information on how to complain and protect service users from abuse, neglect and self-harm. EVIDENCE: The pre-inspection questionnaire received by the CSCI has confirmed that there have been no complaints or safeguarding adult referrals since the last inspection visit. The pre-inspection questionnaire states that no service users maintain their own benefit books or handle their own financial affairs. It was noted that one service user has savings but a relative and trustees handle this. Other service users have their personal allowances paid into individual bank accounts. Each service user has a financial record for any personal expenses. A running total of is kept of monies recorded and receipts are kept on file. One service users money was counted and verified as correct during the site visit. It is recommended that petty cash tins be kept in a locked cabinet. Another employee of Ashcroft Care undertakes an annual audit of all monies and financial transactions. It is recommended that the home access a copy of the most up to date Surrey Multi Agency procedures for the protection of vulnerable adults. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 15 Please see recommendations section of this report. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 24, and 30 were assessed. This judgement has been made using available evidence including a visit to this service. The home is well maintained apart from two minor areas. However it does create a homely feel for service users to live in. EVIDENCE: There is a nice clean and homely feel to the house. The home has three bedrooms on the first floor and one ground floor bedroom. The lounge has been redecorated and a new carpet has been laid. The house has a wellmaintained garden to the rear with seating and a summerhouse. The summerhouse is heated so gives a year round place for service users and relatives to enjoy. There is a fishpond and patio area. The garden is mainly laid to lawn. The kitchen has all the facilities that the service users need and was clean and tidy. The inspector observed that service users like to help out in the kitchen. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 17 The service users bedrooms are all individually decorated to their tastes and house their personal belongings. There is a utility room with a washing machine and tumble dryer. The handle on the desk drawer must be fixed to ensure that staff or visitors to the office are not harmed. Skirting boards in the upstairs bathroom must be cleaned. Please see requirements section of this report. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 32, 34 and 35 were assessed. This judgement has been made using available evidence including a visit to this service. Service users are supported by appropriately trained staff and protected by the home’s recruitment policies and procedures. EVIDENCE: There were three staff on duty on the morning of the inspection. Staff records show that regular supervision is provided and that training and development opportunities have been accessed. Recruitment records are held centrally in Ashcroft Care Services head office and contained all of the documents required. The service is to further improve its current practice by developing a document, which will be in each staff members file with all of the relevant data required by CSCI. Interviews are conducted using the company’s equal opportunities procedures ensuring a fair and open recruitment process is undertaken. Job descriptions were sampled during the visit and these gave clear instructions to staff on the duties required within their role. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 19 There is a training manager in post for Ashcroft Care Services who plans and organises the training programme on an annual basis. Where there are training needs identified within supervision sessions these can be accommodated. Each member of staff has an individual development and performance plan. Training undertaken includes Challenging behaviour, Autism, Report Writing, Manual Handling, Protection from Abuse, Fire Training, Food Hygiene, Epilepsy, NVQ Level 2, Health and Safety, 1 day first Aid and 4 day first aid and first aid renewal. There is a proactive approach within the organisation to ensure that staff are trained on Equality and Diversity and a leaflet was seen in the home during the visit giving information to staff and a training session is to follow. A distancelearning programme for medication is undertaken by staff and ten staff are undertaking NVQ Level 2 via a paperless portfolio route. Please see recommendations section of this report. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 37,39 and 42 were assessed. This judgement has been made using available evidence including a visit to this service. The home is run in the best interests of the service users. There is a quality assurance manager employed by the service to ensure that the views of service users are heard and any changes to improve the service are made. Health and safety policies and procedures are in place to ensure the well being of service users, staff and visitors to the home. EVIDENCE: The inspector was informed that the registered manager has completed level 4 NVQ and is going to undertake the Registered Managers award. Three staff were on duty in the morning including a shift leader. Ashcroft Care Services has a quality assurance manager who ensures that the views of service users and any improvements that are required are listened to and where appropriate action is taken. A report outlining the Quality Assurance Survey results has been received by CSCI. The findings from the Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 21 survey results from everyone who is a stakeholder in the services will feed into the organisation’s strategic planning and this will assist to drive up standards. Positive comments received from relatives include the following: “Staff are pleasant, courteous and pleased to see them, and that they paid interest in the parents relationship with their son”. “I’m very happy with the care that my brother receives at Briarways”. “He has been happy and settled now for ten years, and I think the house makes a great effort to provide stimulation, activity and security”. Health and safety policies and procedures are in place and records are held within the home in relation to environmental health, testing of electrical equipment and fire safety. The accident and incident book has not been kept in accordance with data protection. All incident forms remain in the book. This was discussed with the deputy manager and it was agreed that these would be filed appropriately. Please see recommendations section of this report. Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 22 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 3 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 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Briarways DS0000013577.V324055.R01.S.doc Version 5.2 Page 23 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 YA30 Regulation 23 (2) (d) Requirement Timescale for action 28/02/07 2. YA30 23 (2) (c) The Registered Person must ensure that skirting boards in the upstairs bathroom must be cleaned. The Registered Person must 28/02/07 ensure that the handle on the desk in the office must be repaired. 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. 2. 3. Refer to Standard YA1 Good Practice Recommendations It is recommended that the service user guide be reviewed and updated to take account of the recent staff changes made within Ashcroft Care Services. It is recommended that details of all service users ethnicity be recorded in assessment records in order that staff can plan and assess any cultural needs of service users. It is recommended that the home request an audit visit from the local pharmacy that provides their medication service to ensure that they are compliant with current best practice. It is recommended that healthcare records be updated as DS0000013577.V324055.R01.S.doc Version 5.2 Page 24 YA2 YA20 3. Briarways YA19 4. 5. 6. 6. YA23 YA23 YA34 YA42 identified by staff of the home. It is recommended that petty cash tins be kept in a locked cabinet. It is recommended that the home access a copy of the most up to date Surrey Multi Agency procedures for the protection of vulnerable adults. It is recommended that locally held recruitment records include details of the relevant documents required by CSCI as planned. It is recommended that the accident and incident records be kept in accordance with instructions. 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