Inspection on 12/04/05 for Burnby Lane 23

This inspection was carried out on 12th April 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Burnby Lane 23 07/11/06

Burnby Lane 23 14/11/05

Burnby Lane 23 05/01/05

Burnby Lane 23 30/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Burnby Lane 23 Burnby Lane Pocklington York YO42 2QB Lead Inspector Brian Hallgate Unannounced 12 April 2005 08:15 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. Burnby Lane Version 1.10 Page 3 SERVICE INFORMATION Name of service Burnby Lane Address 23 Burnby Lane, Pocklington, York, YO42 2QB 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) 01759 302602 01759 302602 MENCAP Post Vacant Care Home 4 Category(ies) of Learning Disability (4) registration, with number of places Burnby Lane Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5th January 2005 Brief Description of the Service: 23 Brumby Lane, Pocklington is a five bedroomed detached home that is registered for four adults with a learning disability. The property is in keeping with the local community and is situated in a country lane a few minutes walk from the centre of Pocklington. The home is run by Mencap. All bedrooms are single rooms. Service users are encouraged to personalise and furnish their own rooms. There is a comfortable lounge/dining area with television and CD player. There is an enclosed garden to the rear of the house. The accommodation is situated on two floors. Access to the first floor is by stairs. Burnby Lane Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over three and a half hours and was an unannounced inspection, which commenced at 8.15a.m. A tour of the home was made with the manager and a number of records were inspected. The three service users, the manager of the home and the member of staff on duty, the service manager and a relative of one service user were spoken to. The staff team were undertaking training in multi-media skills and part of this training was observed. What the service does well: What has improved since the last inspection? A manager had been appointed to lead the staff team. She is getting to know the service users, the staff team and the procedures at the present time. The necessary electric safety certificate had been obtained after an examination of the electrical supply to the home. Burnby Lane Version 1.10 Page 6 What they could do better: 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. Burnby Lane Version 1.10 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 Standards Statutory Requirements Identified During the Inspection Burnby Lane Version 1.10 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 standard(s) 2 The assessment prior to admission of the most recently admitted service user is comprehensive and provides an informed decision about moving into the home. EVIDENCE: Two of the service users had lived in their home since it opened in 1991. These service users were admitted from hospital and there were no records of assessments being made prior to admission. One service user had lived in his home since 2002 and a full written care management assessment had been made prior to his admission. This contained details of his needs that this home appeared to be able to meet. The manager of the home and the service manager stated that it is the policy of Mencap to only admit new service users following a full care management assessment. Burnby Lane Version 1.10 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 standard(s) 6, 7 and 9 There is a clear planning system in place to provide staff with the information needed to care for the service users. The plans are usually reviewed on a regular basis. EVIDENCE: There are comprehensive plans of care available for all three service users. The service users attend the reviews of their care plans but only one of the service users would be able to contribute verbally to his review. One service user has no verbal communication skills and another service users has poor verbal skills and often does not understand fully questions put to her. The plans contain details of the service users daily living skills, personal care needs, interests and dietary needs. Risk assessments have been completed on different activities and the assessments are available in the service users files. Staff were observed to enable service users to be as independent as possible and also available to assist where necessary. Because of the complex needs of two of the service users staff have to assist them in making decisions about some aspects of their lives. Burnby Lane Version 1.10 Page 10 Reviews of the care plans had been undertaken on service users since their admission, two reviews were up to date and one service users plan had not been reviewed since 25th May 2004. Burnby Lane Version 1.10 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None EVIDENCE: Burnby Lane Version 1.10 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 standard(s) 18, 19, 20 and 21 The health needs of service users are met with good access available to specialist services when required. EVIDENCE: The service users were observed to receive support from staff when they needed it. They did encourage the service users to undertake as many tasks as independently as possible. All service users are registered with a GP. Specialist health services are arranged through the GP practice. Access to services provided by chiropodists, dentists, opticians and physiotherapist are arranged by the staff as required. No service user is able to self medicate. The home has a monitored dosage system for two of the service users who need medication. The records and the medication were checked and found to be up to date and in order. Medication is locked in a secure cupboard. All staff have received accredited medication training. A recommendation at the last inspection that service users records should contain information about what they and their families want to happen in the event of their death had not been actioned. Mencap have an appropriate form and the manager stated that she would obtain and complete the forms with the families. Burnby Lane Version 1.10 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 standard(s) 22 and 23 The home have satisfactory complaints and abuse policies and there was some evidence that staff listen to relatives and act upon any concerns. EVIDENCE: Observation showed that the staff had time to listen to the service users and involved them in daily living skills. A relative of one service user stated that she was very pleased with the care that the staff gave her relative. If she had any concerns she would speak directly to the staff on duty. She stated that her wishes had always been acted on. There is a complaints policy and procedure. Details of the stages of the complaints policy are also included in the service users guide, given to service users and their relatives. No complaints had been made. There is a policy on abuse and staff spoken to were fully aware of what action to take in the even of a suspected abuse situation. Burnby Lane Version 1.10 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 standard(s) 24 and 30 The standard of the environment of the home is good and provides service users with a clean and homely place in which to live. EVIDENCE: The home is a domestic style detached house with four bedrooms. One bedroom is on the ground floor. There is a lounge/dining room, kitchen, utility room and a staff sleeping in room. The three upstairs bedrooms are accessed by stairs. The home is adequately decorated and furnished to the individual tastes of the three service users. There is one vacancy at the present time. The home is very clean and hygienic throughout. A relative spoken to who visits the home regularly stated that the home was comfortable, she was always made welcome and that the home was kept clean. Burnby Lane Version 1.10 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None EVIDENCE: Burnby Lane Version 1.10 Page 16 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 and 42 The home reviews its performance through an annual audit and considers views from staff, relatives and those service users who can contribute. EVIDENCE: The home has been without a manager. A requirement at the last inspection was that a manager should be appointed by 28th February 2005. A manager commenced employment in the home with effect from the 1st February 2005. She has completed the application form to become the registered manager of the home and forwarded it through her line management. There was a friendly, homely atmosphere between service users, management and support staff. The team were undertaking training and there was a good team spirit between the members of the team who involved the two service users at home throughout the training. Mencap have a quality assurance system where a manager for another service undertakes a quality audit of the home. Any points raised in the audit are implemented within the home. Burnby Lane Version 1.10 Page 17 Arrangements were in place for the protection of service users. The fire alarm weekly test, service of fire fighting equipment, hot water temperatures at a bath and a service users sink, the gas safety certificate and the electrical safety certificate were all in order. All records examined were up to date. 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No Standard No 31 32 Score x x Page 18 Burnby Lane Version 1.10 11 12 13 14 15 16 17 x x x x x x x 33 34 35 36 x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 Standard No 37 38 39 40 41 42 43 Score 1 3 3 x x 3 x Burnby Lane Version 1.10 Page 19 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 37 Regulation 8 Requirement The registered provider must ensure that a registered manager is appointed. Timescale for action 30/04/05 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. 2. Refer to Standard 6 21 Good Practice Recommendations Care plans should be reviewed at least every six months The service user records should contain information about what they and their families want to happen in the event of their death. Burnby Lane Version 1.10 Page 20 Commission for Social Care Inspection York Area Office Unit 4, Triune Court Monks Cross York, YO32 9GZ 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 Burnby Lane Version 1.10 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!