Inspection on 14/11/05 for Burnby Lane 23

This inspection was carried out on 14th November 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burnby Lane 23 07/11/06

Burnby Lane 23 12/04/05

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 23 Burnby Lane Pocklington York East Riding Of Yorks YO42 2QB Lead Inspector Ms Wilma Crawford Unannounced Inspection 14th November 2005 09:30 Burnby Lane 23 DS0000019634.V264713.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 Burnby Lane 23 DS0000019634.V264713.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. Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burnby Lane 23 Address 23 Burnby Lane Pocklington York East Riding Of Yorks YO42 2QB 01759 302602 01759 302602 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) Royal Mencap (Housing & Support Services) *** Post Vacant *** Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th April 2005 Brief Description of the Service: 23 Burnby 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. The accommodation is situated on two floors. Access to the first floor is by stairs. All bedrooms are single rooms and residents are encouraged to personalise and furnish their own rooms. There is a comfortable lounge/dining area with television and CD player. An enclosed garden is situated to the rear of the house. Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 5 hours. A tour of the premises was conducted with a member of staff. The main method of inspection used was called case tracking which involved selecting three residents and tracking the care they receive through the checking of their records, discussion with one resident, the care staff and observation of care practices. The acting manager assisted the inspector for part of the inspection. 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. Burnby Lane 23 DS0000019634.V264713.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 Burnby Lane 23 DS0000019634.V264713.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): 3,4,5 People are provided with the information they need to make a decision to move into the home. Information is gathered about people to ensure that their needs can be met in a safe way. EVIDENCE: The assessment tool used enables staff to gather a lot of information about prospective residents. Arrangements are made for staff to meet with the prospective residents and to gather information from various sources including the service user and where appropriate the care manager. Residents are invited to visit the home and to move in on a trail basis before a decision is made about them moving in permanently. All of the service users had a copy of their agreed contract with the home and placing authority on their files. Burnby Lane 23 DS0000019634.V264713.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): 8,9 Service users are enabled to live as independently as possible taking into account any risks that need to be considered. EVIDENCE: The care plans looked at gave clear information about all aspects of the service users personal and social support and health care needs. The care plans are generated from the assessments and they set out how the service users needs are to be met and by whom. There was information about the type and level of support they need and information about what they do independently. The service users are involved in planning their care. Each service user has a key worker, this arrangement ensures that they have one to one time and support with the activities of daily living and time to discuss any problems or concerns they may have. There was up to date information about any treatments and interventions from external health care professional including input from the mental health services. Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 9 Risk is assessed and service users are given guidance about how to minimise risks to enable them to maintain an independent lifestyle. There are systems in place for staff to keep regular records about the service users and for the review of their care. Regular residents’ meetings are held and records of these kept. Burnby Lane 23 DS0000019634.V264713.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): 12,13,15,16,17 There are a wide range of educational, occupational and leisure activities available, to ensure that service users have a varied and enjoyable timetable. EVIDENCE: At the time of the inspection, one resident was at day services and a second was collected during the inspection. The remaining two went out after lunch. The manager and staff said that there were regular outings organised from the home, and two vehicles are available to enable this. Residents had also enjoyed a holiday to Butlins in Skegness. Records of activities were documented in individual care plans and discussed at residents meetings. Residents in the home have profound learning disabilities and were unable to comment, however they were observed engaged in activities. The staff demonstrated a good knowledge of individual dietary needs, and explained how individual preferences are catered for. Mealtimes appeared well organised and relaxed. Staff were observed to be offering a high level of encouragement and support to a resident who had refused to eat their meal, including offering food alternatives. Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 11 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): 19,20 There are good links with health care services, ensuring that health needs of residents are met. EVIDENCE: There was widespread evidence of referrals to health care services to meet residents’ needs. All residents are registered with local GP surgeries, and letters relating to outpatient appointments, and referrals to specialists were on file. There are satisfactory arrangements for optical and dental provision. Administration records were satisfactory on this occasion, as were storage and stocktaking arrangements. Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 12 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): These outcomes were not looked at. EVIDENCE: Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 13 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): 25,27,29 The residents live in a comfortable, pleasant and safe environment, with both private and communal space being suitable for their needs. EVIDENCE: Residents’ bedrooms were personalised with photographs, pictures and personal belongings. They also have the opportunity to bring their own furnishings into the home if they wish. There are two bathrooms in the home with grab rails and a shower chair, which are suitable for individual needs. Washbasins are provided in each bedroom. The leg of the shower chair was rusty and needs to be repaired to maintain residents safety. A bolt is fitted to the upstairs bathroom, to replace a faulty two-way lock, a requirement has been made to repair to lock and remove the bolt, to ensure resident safety is not being compromised. The home is generally well maintained and the décor is satisfactory. The hall and landing is showing signs of wear and tear and is in need of redecoration. Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 14 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): 32,34,35,36 Staff are well trained and supported, and there are sufficient numbers to meet the needs of service users. Recruitment and selection procedures are robust, ensuring that service users are protected. EVIDENCE: Two staff available in the morning and one in the evening and overnight. When four residents are in the home two staff are available in the evening. The staff recruitment and selection procedure is robust and the required staff records were in place. There was evidence that the required references had been taken up and the required CRB and POVA checks undertaken prior to all new staff taking up their positions. All staff are subject to an induction and statutory training, which includes, protection of vulnerable adults, fire safety, food handling and first aid. Staff meetings are held on a regular basis and records are kept of the outcomes and the actions agreed. All staff are supervised providing them with an opportunity to discuss training needs and any issues of concern. Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 15 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 service users benefit from a well managed home. EVIDENCE: The acting manager is qualified, competent and experienced to run the home and meet the aims and objectives. She has made an application to become the registered manager of the home. Staff spoken with felt confident to approach the acting manager and that they would be listened to. Staff meet on a daily basis to discuss the needs of the service users and the arrangements for the day. Burnby Lane 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 16 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 X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Burnby Lane 23 Score X 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 X X X X X X DS0000019634.V264713.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection?YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA24 YA24 Regulation 23(2) 23(2) Requirement The bolt on the bathroom door must be removed and the correct lock repaired. An action plan must be forwarded to the Commission to address the redecoration of the entrance hall andlanding. The shower chair in the downstairs bathroom must be maintained in a good state of repair. A minimum of 50 of trained care staff(NVQ level 2 or equivalent)is achieved by 2005, excluding the registered manager. The registered provider must ensure that a registered manager is appointed.(Previous timescale of 30/04/05 not met) Timescale for action 30/11/05 31/03/06 3. YA29YA 23(2) 31/03/06 4. YA32 18 31/12/05 5. YA37 8 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. Refer to Good Practice Recommendations DS0000019634.V264713.R01.S.doc Version 5.0 Page 18 Burnby Lane 23 1. 2. Standard YA6 YA21 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 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF 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 23 DS0000019634.V264713.R01.S.doc Version 5.0 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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