Inspection on 19/12/05 for Briarwood Drive, 69

This inspection was carried out on 19th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Briarwood Drive, 69 30/11/06

Briarwood Drive, 69 28/06/05

Briarwood Drive, 69 14/09/04

Briarwood Drive, 69 05/05/04

Briarwood Drive, 69 23/02/04

Briarwood Drive, 69 22/07/03

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Briarwood Drive, 69 Santa Care Homes 69 Briarwood Drive Northwood Hills Middlesex HA6 1PW Lead Inspector Mr Gavin Thomas Unannounced Inspection 4:20 19 & 21 December 2005 th st Briarwood Drive, 69 DS0000027085.V261366.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 Briarwood Drive, 69 DS0000027085.V261366.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. Briarwood Drive, 69 DS0000027085.V261366.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Briarwood Drive, 69 Address Santa Care Homes 69 Briarwood Drive Northwood Hills Middlesex HA6 1PW 0208 429 1971 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) Ms Santa Bapoo Ms Santa Bapoo Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Briarwood Drive, 69 DS0000027085.V261366.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user who is visually impaired can be accommodated, as agreed by the Commission for Social Care Inspection, on 27th June 2005. The condition of registration will only apply for as long as the service user`s assessed needs can be met. The home must advise CSCI when the service user no longer resides at the home. 28th June 2005 Date of last inspection Brief Description of the Service: 69 Briarwood drive is a three - bedded care home for service users with Learning Disabilities. It is a semi - detached house situated in a residential area close to a parade of shops at Northwood Hills and to transportation. Medical services are provided by a local GP and within walking distance. The home is owned and managed by a sole Proprietor. The home is in keeping with local ambience and provides off street parking for up to 2 vehicles. An attached garage is used primarily as a storage facility. The home has a rear garden, most of which is laid to lawn. Briarwood Drive, 69 DS0000027085.V261366.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over two days for a period of 4.45hrs. During this time, the Inspector met with the Deputy Manager and spoke with the two service users and one member of staff. One service user said that apart from having a visual impairment, they had settled in the home and had no concerns about the placement. With the exception of information on quality assurance and monitoring systems, all other records and documents required for inspection purposes were accessible. What the service does well: What has improved since the last inspection? It was noted that various items such as a wipe board, picture frames and ornamental fixtures were left on the walls in the lounge/diner without being removed and/or destroyed by one service user, who previously could not tolerate paper or ornamental items being left around the house. Both staff and the service user are to be commended for this achievement. Out of the twenty-three requirements identified at the last inspection, nineteen were met, one was partially met and three were not met. Briarwood Drive, 69 DS0000027085.V261366.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Briarwood Drive, 69 DS0000027085.V261366.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 Briarwood Drive, 69 DS0000027085.V261366.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): 1 The home’s Statement of Purpose and Service User Guide have much improved. Both documents are now easier to read and give a clearer account about the ethos of the home and provisions of service. The home is to be commended for this achievement. EVIDENCE: The Statement of Purpose and Service User Guide are now two separate documents. The content of the Statement Of Purpose was in keeping with the criteria as set out in Schedule 1 of the Care Homes Regulations. The content and style of the Service User Guide has been tailored in accordance with the needs of service users intended for this service. Briarwood Drive, 69 DS0000027085.V261366.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): 7 The staff are continuously learning about the needs of the service users’ to ensure that their care and support needs are met. The Deputy Manager is doing well in identifying appropriate training for staff and support from external professionals and organisations who have been of assistance to the home. EVIDENCE: The two service users currently residing at the home have named Social Workers. Both service users are in contact with their relatives who advocate on their behalf. Both service users are encouraged to make decisions about their lives. The home supports service users wishes and decisions when it is reasonable and practical to do so. The home has mastered a communication system with one service user, which is proving successful. One service user has a visual impairment. The service user has good verbal communication. This was observed at the time of the inspection. Briarwood Drive, 69 DS0000027085.V261366.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): 16 & 17 The home provides a good range of opportunities for both service users to exercise choice and control over their lives as far as is practicable to do so. The meals in this home are good offering choice and variety, however the way in which meals are recorded must be more detailed. EVIDENCE: The two service users currently living at the home do not hold keys to their bedrooms or the main entrance to the home. The Deputy Manager explained that service users are not capable of managing keys for safety reasons. This must be evidenced via the risk assessments for both service users. Service users can choose when they want to be on their own or with others. This was observed at the time of the inspection. This is a small family sized home. The home was in the process of exploring ways to stop one service user entering the other service user’s bedroom when they were not invited to do so. This was causing some degree of anxiety and upset towards the other service user. Briarwood Drive, 69 DS0000027085.V261366.R01.S.doc Version 5.0 Page 11 Both service users had set routines, which were set out in their care plans. Service users involvement in housekeeping tasks were also recorded on their care plans. Where possible, both service users are encouraged to be selfmanaging and independent. Rules on smoking were identified on the risk assessment for one service user. One service user receives their mail unopened. The Deputy Manager explained that staff offer to open and read mail with one service user who has a visual impairment. The Deputy Manager explained that service users have supervised access in the rear garden for safety reasons. Staff are required to knock on service users bedroom doors before entering. This was observed at the time of the inspection. The Inspector observed staff talking with service users. The Deputy Manager works closely with staff and service users. He has established very good relationships with both service users. The main meal of the day is served in the evening. Staff monitor service users food intake. This is the case for one service user in particular who appears to go through phases whereby they refuse to eat substantial meals. Where possible, service users are involved in purchasing foods and the preparation of meals. Meals are selected by service users. Drinks and snacks are available to service users through out the day. Comfortable dining facilities are provided. A record of food taken by service users is kept. Currently, the blank spaces in the record of served does not determine if service users refused a meal, if they ate out, had a take away or any other reason. These details must be added for monitoring purposes. Briarwood Drive, 69 DS0000027085.V261366.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): 21 The home should seek to secure information about service users’ last wishes in the event of death to ensure that these wishes are respected in the event of death. EVIDENCE: Although both service users have regular contact with relatives, the home should consult with relatives and where possible the service users regarding last wishes in the event of death. The details should include any observation of religious and cultural customs. Briarwood Drive, 69 DS0000027085.V261366.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): 23 Overall procedures and systems in place for the safety and protection of service users were satisfactory. However, the home must still obtain other documentation on the safety and protection of vulnerable people, to maximise staff awareness about reporting and responding to known or suspected incidents of abuse. EVIDENCE: Staff attended adult protection training in November 2005. The Deputy Manager confirmed that there were no known concerns regarding the safety or protection of both service users. The Deputy Manager explained that staffing levels reflect service users’ needs to maximise their safety and protection. The home must obtain a copy of the Department of Health “No Secrets” document. This requirement remains outstanding from the previous inspection. The home was in receipt of the London Borough of Hillingdon’s adult protection policies and procedures. The home was strongly advised to obtain copies of the adult protection policies and procedures from the two Placing Authorities. Briarwood Drive, 69 DS0000027085.V261366.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 The standard of décor in this home was satisfactory with evidence of future improvements to the ground floor. Furniture and fixtures were judged to be comfortable and homely. EVIDENCE: The home was clean and well presented throughout. A window was broken in the toilet on the ground floor. The Inspector did request that this window was made safe as a matter of urgency. The window was repaired at the time of the inspection. Proposals are in place to convert the garage into an en suite bedroom. Timescales for this conversion have not been established. This conversion will also include a utility room. The home is required to communicate with the Commission for Social Care Inspection prior to building work commencing. This is to ensure that all safety measures are in place. A record of all maintenance work undertaken was in place. The home must develop this record into a “planned” maintenance and renewal programme for the fabric and decoration of the premises. Briarwood Drive, 69 DS0000027085.V261366.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): 32, 34 & 35 The home has now established a small and stable staff team. Staff are doing well in working positively with service users to improve their whole quality of life. The home has made good progress in accessing relevant training opportunities for staff since the last inspection. However, the training programme must be more focused on the types of training identified for staff for at least the next year. EVIDENCE: The staff team consists of: The Registered Manager. One Deputy Manager. Three Support Workers. One sleeping –in staff. There are two staff on duty throughout the day until 7pm. One Support Worker is on duty between 7pm and 8pm. The night duties starts at 8pm. The home does not use external agency staff. Staff from another home owned by Santa Care Homes also work at this home. One to one staff support is provided during the day for the two service users currently living in the home. Briarwood Drive, 69 DS0000027085.V261366.R01.S.doc Version 5.0 Page 16 Two permanent staff were recently employed. One full time member of staff had moved on since the last inspection. One part time Support Worker has an NVQ Level 3 in care. The two staff most recently employed were working towards the NVQ Level 2 in care. The Deputy Manager has achieved the NVQ Level 2 in management and care and was working towards the Registered Managers Award (RMA). Progress towards the completion of NVQ’s will be monitored at the next inspection. The Deputy Manager explained that the two new staff would be required to attend relevant training once they have completed their probationary period. Staff have attended training with the RNIB and mental health training since the last inspection. The Deputy Manager explained that the home is making good progress in establishing networks with external professionals. A recruitment policy was in place. The Deputy Manager confirmed that two staff carries out interviews with prospective staff. There were no staff vacancies at the time of this inspection. The home was in receipt of a copy of the codes of conduct and practice as set by the General Social Care Council. Recruitment checks are carried out in accordance with the criteria as set out in Schedule 2 of the Care Homes Regulations 2001. However, the home must obtain a recent photograph of all staff. This must be retained on individual staff files. The Deputy Manager said that written interview notes are destroyed. This evidence should be retained for good practice purposes. Although a staff-training programme was in place, the programme only included training programmes already undertaken by staff. The home must devise and implement a more detailed training and development programme, which must be devised in accordance with a dedicated training budget. This requirement from the previous inspection is only partially met and is restated for this visit. Briarwood Drive, 69 DS0000027085.V261366.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 The Registered Manager is supported well by the Deputy Manager who demonstrates clear leadership and whose approach is focused on engaging service users in meaningful activities and supporting them to live as part of the community. EVIDENCE: The Registered Manager is supernumerary to the staff team. The Registered Manager qualified as a nurse in 1997. The Registered Manager has been operating residential care services since 1989. The Registered Manager is working towards the Registered Managers Award (RMA). The Deputy Manager is responsible for coordinating the day to day running of this establishment. The Deputy Manager is accountable to the Registered Manager who is overall responsible for the running of the home. Briarwood Drive, 69 DS0000027085.V261366.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 3 x x x x Standard No 22 23 Score x 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 x x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 x 16 2 17 Standard No 31 32 33 34 35 36 Score x 3 x 2 2 X CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Briarwood Drive, 69 Score x x x 2 Standard No 37 38 39 40 41 42 43 Score 3 x 2 x x x x DS0000027085.V261366.R01.S.doc Version 5.0 Page 19 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. Standard YA16 Regulation 13(4)(c) Requirement Timescale for action 28/02/06 2. YA17 3. YA23 4. YA24 5. YA34 6. YA35 7. YA42 The reasons for service users’ not having keys to their bedrooms must be evidenced via their risk assessments. 17(2) Sch 4 The blank spaces in the record (13) of served must determine if service users refused a meal, if they ate out, had a take away or any other reason. These details must be added for monitoring purposes. 13(6) The home must obtain a copy of the Department of Health No Secrets guidance document. (Timescale of 31/8/05 Not met). 23(2)(b)(d) The home must devise a “planned” maintenance and renewal record for the fabric and decoration of the premises. 19 Schedule The home must obtain a 2 (1) recent photograph of all staff. This must be retained on individual staff files. 18(1)(a)(c)(i) A training and development programme must be devised and implemented. (Timescale of 31/7/05 Not Met). 23(4)(b) A fire emergency route DS0000027085.V261366.R01.S.doc 31/01/06 28/02/06 31/03/06 31/01/06 28/02/06 31/01/06 Page 20 Briarwood Drive, 69 Version 5.0 planner must be devised and implemented. (Timescale of 31/7/05 Not Met). 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 YA21 Good Practice Recommendations The home should consult with relatives and where possible the service users regarding last wishes in the event of death. The details should include any observation of religious and cultural customs. The home should obtain copies of the adult protection policies and procedures from the two Placing Authorities. This home should retain written notes, which are taken at staff interviews. 2. 3. YA23 YA34 Briarwood Drive, 69 DS0000027085.V261366.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection West London Area Office 58 Uxbridge Road Ealing London W5 2ST 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 Briarwood Drive, 69 DS0000027085.V261366.R01.S.doc Version 5.0 Page 22 - 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. 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