Inspection on 07/11/06 for Burnby Lane 23

This inspection was carried out on 7th November 2006.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burnby Lane 23 14/11/05

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 Terry Downey Key Unannounced Inspection 7th November 2006 09:00 Burnby Lane 23 DS0000019634.V322025.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 Burnby Lane 23 DS0000019634.V322025.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. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burnby Lane 23 Address 23 Burnby Lane Pocklington York East Riding Of Yorks YO42 2QB 01759 302602 F/P01759 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) www.mencap.org.uk Royal Mencap Society Mrs Paulette Marie Gill Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 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. The registered manager is Mrs Paulette Gill. On the 7th November 2006 the fees for the home ranged from £787 86 to £1009.23 Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection consisted of a review of the information held on the homes file since the previous inspection, information submitted by the home in the Pre Inspection Questionnaire, and a 4 hour unannounced site visit to the home on 7th November 2006. At the time of the site visit the manager Mrs Gill was available, with one member of staff in the home, and four service users, two of whom were preparing to go to day services. They all assisted with the inspection, and were very helpful. It was difficult to communicate with the residents but staff assisted which was very helpful, but some of the comments are also based on observation. The site visit also included discussion with the staff, a check on the requirements and recommendations from the previous inspection, a tour of the premises and a check on the records kept by the home. Survey forms were completed by four people and all were complimentary about the home, the staff and the care provided. Some of the records examined were not up to date because the manager spends three days per week as a carer and only two days on management tasks. It was suggested that more time should be spent on management duties. The inspection showed that the residents were well cared for in a clean, well maintained, home. The home has had to use a lot of agency staff which is not appropriate for the residents but the manager is making efforts to recruit permanent staff and some success was seen. There is a core of well trained and committed staff, and a manager, who work hard to improve the residents’ quality of life and this was also witnessed. What the service does well: The residents live in a clean, well maintained home. Staff are kind and helpful and make an effort to provide the service the residents’ want. Residents are able to make choices in many areas of their lives. Examples included rising and retiring times, activities, clothes, and food. This ensures that they maintain some control. The residents are able to access the primary health care team and other professionals ensuring that their health care needs are met. A good choice of well prepared food, and drinks are available. This ensures that they receive a varied and nutritious diet. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 6 The staff are provided with comprehensive training to improve their knowledge and skills. This promotes best practice and ensures that residents receive a good quality service. Staff are recruited in a way that seeks to make sure that only suitable people are employed and ensuring the safety and protection of the residents. 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. The summary of this inspection report can be made available in other formats on request. Burnby Lane 23 DS0000019634.V322025.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 Burnby Lane 23 DS0000019634.V322025.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information required to choose a home which meets their needs. EVIDENCE: The most recent admission to the home in April 2006 was poorly recorded. A detailed assessment was received from a close relative but there was no assessment from the home and the care plan from Social Services was dated 2003. Despite this there was evidence of good contact with the close relative, visits prior to admission were well documented, and the staff were very knowledgeable about the service users needs. Two service users files examined showed that the needs of people who use the service are regularly reviewed and that every effort is made to ensure that service users are involved in determining how their needs and aspirations will be met. There was information available about the home to give to prospective residents which included the Service User Guide, and an information pack. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 9 Staff were able to demonstrate that they had the information to ensure they could meet the social, emotional and care needs of new residents but much of this was transferred verbally rather than written which is not reliable. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 10 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): 6, 7, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Care plans must be kept up to date and include changes in patterns of behaviour. All information must be recorded rather than passed on verbally. EVIDENCE: Two residents were case tracked and this indicated that their personal care needs were met appropriately. Efforts are made to involve the residents in their care plan but it would be difficult to verify their understanding of it. Each service user has a key worker, which helps to give them one to one time and support with the activities of daily living and time to consider any problems or concerns they may have. The care plans were satisfactory and developed using the principles of person centred planning. They contained the information required to help the staff Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 11 meet the needs of the individual resident and were set out in an easy to read and understand format. There was some evidence that they were not up to date and did not record changes in patterns of behaviour. In one case an assessment from a community nurse was not included in the care plan although the information had been shared with staff verbally. The care plans must be kept up to date and record changes in behaviour, the reasons, and how to deal with the changes. Staff had a good understanding of the needs of the residents and were knowledgeable about the contents of their care plans and risk assessments. They were seen to be patient and kind when interacting with the residents and clearly provided individual care. The residents were unable to communicate verbally but with the help of staff expressed levels of satisfaction with the home and their care. Surveys confirmed that relatives were consulted and kept informed about important matters. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The social and recreational activities meet the residents’ needs and they eat a healthy and varied diet. EVIDENCE: Each resident has an individual timetable designed to ensure that they are given the opportunity to take part in a variety of activities both within the home and the community, and staff are available to support them. The staff are constantly looking for new activities which will interest the residents and provide further stimulation and development to enable them to live an ordinary and meaningful life. All Four residents were in the home at the start of the inspection but two were going to day services, and information in the home showed very good liaison between the home and the day services to ensure continuity and development of skills. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 13 There was evidence that the disability equipment required has been obtained and environmental adaptations made to meet the needs of the service users. Menus were varied and nutritionally balanced. Mealtimes were said to be relaxed and social events. Two residents had breakfast during the inspection and the assistance and support from staff helped to make it a pleasant experience for them. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 14 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): 18, 19, 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The residents are well supported and the medication procedures ensure that their health care needs are met. EVIDENCE: There was a lot of evidence to demonstrate good liaison with the healthcare services and this clearly benefits the residents and gives the staff the support and guidance they require to meet the complex needs of the residents. Specialist health and dietary requirements were recorded and provide an overview of each resident’s health needs. They also act as an indicator of the change in their healthcare needs. Staff understand the principles of giving personal support and are responsive to the individual requirements of each resident. Attention is given to ensuring privacy and dignity when delivering personal care and staff are sensitive to the changing needs of residents. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 15 The home’s medication procedure was observed and staff were able to explain the individual procedure for each resident. Medication was safely stored and records were well maintained and up to date. Information for each resident was clearly marked and contained information about their individual medicines. None of the residents administer their own medication. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 16 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): 22, 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse but it is important that the correct procedure is followed by the management of the home. EVIDENCE: The complaints procedure is available to all the residents in varying formats and is easily available. Because of the residents’ complex needs the staff explained that they have to be alert to subtle changes in behaviour and check out the causes to establish if a resident is not happy. Staff had a good understanding of service users’ rights as citizens. The evidence indicated that residents are protected from abuse; the staff were enrolled for a training course in December regarding adult abuse. There was some evidence that an incident had occurred in the home which had not been reported correctly although dealt with by the managers of the home. All allegations of abuse must be reported to Social services and the Commission. It was recommended that the managers of the home revisit the procedure and that the training provided for staff is regularly reinforced at staff meetings. The recruitment procedure is good and ensures that only suitable people are employed in the home. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 17 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): 24, 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home enables residents to live in a safe, well maintained and comfortable environment. EVIDENCE: The home was clean, well decorated and furnished and appropriate to the needs of the residents. Major decorations are carried out by the Housing Association which owns the home but minor works are done by the home. Residents also decorate their own bedrooms, with staff support, to their choice, and they all personalise their rooms. There was very good access to the garden which was tidy and well maintained. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 18 There was a programme of routine maintenance and decoration for the home, and a good infection control policy which ensures that it is always a safe and comfortable place to live. Specialist equipment was provided in the home and all was of good quality and serviced regularly and met the needs of the residents. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 19 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): 32, 34, 35, 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents benefit from a well trained and committed staff team. EVIDENCE: The rota showed that there were sufficient staff on duty and this was confirmed during the inspection. Staff were observed assisting the residents and also having time to spend talking and caring for him. It was clear observing the interactions between the staff and the residents that there was a mutual respect and staff tried to help the residents, and involve them in their care rather than do it for them. Two staff files were inspected and the records were well maintained and showed that there was a robust recruitment procedure. A lot of Agency staff have been employed in the home during the past 6 months and the manager explained that a member of staff had been on long term sick leave. It is not ideal for the residents in this home to have staff who Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 20 do not know them well, but the manager said that she had tried to ensure that the Agency sent staff who were known to the residents. The home has appointed two new members of staff this year to add to a well established staff team, which provides stability for the residents. A good induction and training programme is in place to ensure that staff are equipped to carry out their jobs well. This training includes the protection of vulnerable adults as well as the mandatory training to meet service users basic needs, such as manual handling and health and safety. Specific training relevant to the needs of the residents was also provided and one of the carers on duty was the home’s representative on the specialist communication workshop. Staff were clear about their role and knew what was expected from them. They said they worked well as a team and that the manager was very good, approachable, and supportive. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 21 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): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Good management arrangements ensure that the home is run to meet the needs of the residents. EVIDENCE: The manager was available on the day of the inspection and was well organised and helpful. She is taking the required qualifications and has the experience and is competent to run the home. There was one other member of staff on duty and she was aware of her responsibilities. She said that staff were kept informed of relevant management issues, and they considered the manager to be very Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 22 approachable and supportive. Survey forms mentioned good communication, good organisation, and satisfaction with the care being provided. Staff considered that they were well supported by the manager and that they worked well together as a team. The manager also has to act as a carer for three days per week and this took her away from her managerial responsibilities. There was some evidence that record keeping/paperwork, especially care plans, were being neglected because of this and it is important that they are kept up to date. It was recommended that she discuss with her line manager having more management time to keep up with the paperwork. The quality assurance in place is based on Mencap’s national and regional systems rather than a specific system for 23 Burnby Lane. There was evidence of a lot of good informal feedback from relatives and stakeholders and a lot of good liaison and joint working. The home has a Health and Safety policy and regular checks and staff training ensure that the home is a safe place to live and work. A senior manager visits the home monthly and talks to residents and staff, and completes a quality audit. Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 23 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 X 2 2 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 1 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 3 3 X 2 3 X Burnby Lane 23 DS0000019634.V322025.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA2 Regulation 14 Requirement Prospective residents must only be admitted following a full assessment of their needs by people competent to carry out such an assessment. Care plans must be kept up to date and include changes in behaviours. Information must be recorded rather than passed on verbally. Any allegations of abuse must be reported to Social Services and the Commission. The managers of the home must ensure that they are fully aware of the safeguarding adults procedure and this should be reinforced to staff at team meetings. Timescale for action 31/12/06 2. YA6 15 31/12/06 3. YA23 13 37 11/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA41 Good Practice Recommendations It is recommended that the manager is allocated more time for managerial duties so that records can be better maintained. DS0000019634.V322025.R01.S.doc Version 5.2 Page 25 Burnby Lane 23 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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