Inspection on 01/03/06 for Burncross Road

This inspection was carried out on 1st March 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 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burncross Road 08/06/09

Burncross Road 27/06/08

Burncross Road 08/06/06

Burncross Road 28/07/05

Burncross Road 14/12/04

Burncross Road 27/07/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Burncross Road 209/211 Burncross Road Chapeltown Sheffield South Yorkshire S35 1RZ Lead Inspector Claire McAuley Unannounced Inspection 09:15 1st March 2006 Burncross Road DS0000002942.V254723.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 Burncross Road DS0000002942.V254723.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. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Burncross Road Address 209/211 Burncross Road Chapeltown Sheffield South Yorkshire S35 1RZ 0114 257 1763 0114 257 1763 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) New Era Housing Association Limited Post Vacant Care Home 13 Category(ies) of Learning disability (13), Physical disability (9) registration, with number of places Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th July 2005 Brief Description of the Service: Burncross Road is a care home providing personal care and accommodation for thirteen residents with learning and physical disabilities. It is situated in the Chapeltown area, close to shops and public transport. The home is purpose built and consists of two properties adjacent to each other. One is single storey with accommodation for six residents, and the other is a two-storey house with accommodation for seven residents. All rooms are single, and one has an ensuite facility. There are pleasant secure level gardens around the home, and a small car parking area. Burncross Road DS0000002942.V254723.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 from 9.15am to 2.30pm. Previous requirements and key standards were checked. Areas of the environment were inspected. Three members of staff were spoken with. Residents were unable to express their opinions on the quality of the service, due to their disabilities. Discussions with the manager and senior support worker took place and a number of records were checked. What the service does well: What has improved since the last inspection? What they could do better: The quality assurance process needed to be re-established to ensure that relatives, and where possible, residents, were asked their opinions on the service, Appraisal and supervision of staff needed to be completed at the required level, although there was a plan in place for this for 2006. A number of assessments in care plans were not dated, and some did not have evidence of updating. Regular weighing of a service user who required this for health reasons had not been completed. The food provided for residents relied somewhat on tinned and processed foods, and there was a lack of fresh ingredients used, particularly at lunchtime. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 6 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. Burncross Road DS0000002942.V254723.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 Burncross Road DS0000002942.V254723.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): 2. Prospective residents were only admitted after a full needs assessment had been carried out to ensure that their needs could be met. EVIDENCE: Prospective residents were only admitted after a full needs assessment had been carried out to ensure that their needs could be met. Burncross Road DS0000002942.V254723.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): 6, 7, 9. Detailed care plans were in place, these were generally of a good standard, although some were not dated or updated. Relatives acted on behalf of the residents, and advocacy services were accessed when necessary. Staff encouraged residents to make choices. Resident’s finances were managed at the home. Risk assessments were in place for the protection of residents. EVIDENCE: Detailed care plans were in place; they were of a good standard and specified the needs of service users and the action taken by staff to meet those needs. Some assessments seen were not dated and others had not been updated. The plans had been written in the person centred planning format. Service users were reviewed regularly, and specialist and therapeutic interventions were included, such as hydrotherapy, speech therapy, and medical treatment, as well as special communication or equipment needs. One resident had not been regularly weighed as required. Families were involved in the decision making process and advocates were sourced for those residents who had no family involvement. Staff members encouraged residents to make daily choices as much as possible by using their Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 10 knowledge of that resident’s communication methods, and by using specialised communication such as pictures. No resident was able to look after his or her own finances. Residents all had individual bank accounts, and records were kept of all transactions. The accounts were independently audited. The residents were not able to take responsible risks due to their limited awareness and capabilities. Risk assessments were in place for each individual in their person centred plans. Generic risk assessments were in place to minimise the risks to the residents in the home environment and outside the home. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 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 the following standard(s): 12, 14, 16, 17. Residents were unable to seek employment or educational training. They were involved in day centres and appropriate activities, which provided stimulation. Yearly holidays as part of the contract price had been organised. Staff treated residents with respect. Staff were aware of residents dietary needs. There was a significant proportion of processed food provided for residents. EVIDENCE: Due to the high dependency of the residents at the home none were able to seek employment or continue educational training. Stimulation was provided by their involvement in day centres, activities within the home, and outings organised by staff. Regular outings took place, including shopping trips, walking group, iceskating, sports centre and horse riding. Community ‘mapping’ was undertaken by staff to build up a good knowledge of the facilities available in the area, and to ensure that the residents could access them. Initiatives to develop different activities were under way. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 12 Some summer holidays for residents had been organised, including a boat holiday and trips abroad. Other residents preferred day trips or short overnight stays. These holidays were now included as part of the basic contract price. Staff were witnessed interacting with, and speaking appropriately and respectfully to residents. Residents were able to access the garden area, which was well laid out and was a pleasant and safe area. Visitors were made welcome. One resident’s parents gave a lot of their time to maintaining the garden area of the home. Residents were involved with the food shopping and meals were flexible to meet individual needs. Appropriate help was offered, Risk factors, such as swallowing difficulties had been assessed. The likes and dislikes of each resident were recorded on their care plan and staff were aware of these. The food provided for residents included a significant proportion of convenience tinned and processed foods, and there was a lack of fresh ingredients used, particularly at lunchtime. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 13 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. Resident’s healthcare needs were met. A health action plan was being introduced for all residents. For the safety of residents, there were policies procedures and staff training in place for the administration of medication. However, there were some discrepancies in medication administration. EVIDENCE: Care plans recorded residents healthcare needs in detail including access to healthcare facilities within the community. Residents were supported to attend GP surgery, dentist, chiropodist, and outpatient appointments and specialist services such as speech and language specialists, occupational therapy and physiotherapy. Resident’s health was regularly monitored and early intervention was in place. Equipment, such as wheelchairs, and special armchairs were provided following assessment. A new health action plan was in the process of completion for all residents; this was intended to provide a more comprehensive picture of the resident’s full healthcare needs. Residents at the home were not able to take responsibility for their own medication. Policies and procedures were in place to ensure that the staff administered medication appropriately. Training was provided for staff in medication administration. Some discrepancies in the medication administration were observed. These included, a cream, which was prescribed Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 14 twice daily, was administered only once daily. There were gaps in the recording of medication on two MAR sheets. Unidentified eye drops had been kept in the fridge and the MAR sheets were not kept with the medication. One of the medication cabinets was untidy. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 15 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): 22, 23. There was an appropriate complaints procedure in place. Staff had received mandatory training on adult protection. Policies and procedures were in place to deal with physical and/or verbal aggression. The residents were protected by the policies, procedure and guidelines followed at the home. EVIDENCE: The home had a complaints procedure which met the standards and regulations. The home had a system to record any complaints received and complaints were dealt with appropriately. The home had a procedure on adult protection and any allegations/incidents of abuse would be referred immediately to Social Services Adult Protection office. The policy had been reviewed to take account of the Department of Health Guidance ‘No Secrets’. The manager confirmed that all staff had received training on adult protection, or were in the process of updating their training. Policies and procedures were in place to deal with physical and/or verbal aggression by residents. Physical intervention was used only as a last resort by the trained staff, protecting the rights and best interests of the residents. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. The home’s environment was of a good standard. There was a refurbishment and renewal programme in place. Redecoration of corridors was taking place. Warped fire doors and emergency lighting required replacement. The building was clean and fresh smelling, and staff had training on the control of infection. Laundry facilities were appropriate. EVIDENCE: The home’s environment was of a good standard and smelled fresh. Furnishings and fixtures were of a good standard. There was a programme of refurbishment and redecoration in place. Some corridor areas required redecoration and this was underway on the day of the inspection. Resident’s bedrooms were well decorated and furnished, each reflecting their personalities. The home had recently had a visit from the Fire Service who had recommended that four warped fire doors be replaced. This was in process. Two emergency lights were also in the process of replacement. Level access to the garden and entrances was provided. The building was clean with laundry facilities sited away from all food preparation and storage areas. Staff had received training on the control of infection. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 17 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): 33, 34, 35, 36. To maintain the safety of service users, the home maintained the required levels of staff. A recruitment procedure was in place that protected the welfare of residents. Relatives were involved in the selection of staff. All new staff members received induction training, and new starters were supervised. There was a programme of supervision and appraisal of staff in place that should ensure that requirements are met in 2006. EVIDENCE: The rotas showed that the home maintained the required levels of staff. Regular relief staff covered sickness and holidays and regular staff meetings took place. Staff members spoken to said there were sufficient staff to meet the needs of the residents. A recruitment procedure was in place that protected the welfare of residents. Staff did not begin work at the home until a CRB check had been completed. Two references, health check, identification and employment history was required. All employees received the GSCC Code of Conduct. A new initiative to involve relatives in the selection of staff had recently been introduced. All new staff members received induction training within six weeks of employment. The programme met National Training Organisation requirements and staff interviewed said it covered such things as safe working Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 18 practices, the organisation and workers role and the needs of the resident group. New starters worked alongside an experienced member of staff, and were supernumerary until they were judged to be competent. Learning Disability Award Framework accredited training was taking place at the home. Records showed that supervision and appraisal of staff had not been taking place at the required level. The acting manager had put a programme of supervision and appraisal in place for 2006. Following the recent staff reorganisation, senior support workers were now supervising support workers, and this programme was under way. Staff members said they felt supported in their work and could discuss any issues with colleagues or management; the home had an open environment. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 19 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, 39, 42. The acting manager was appropriately qualified and experienced and had applied to be registered manager of the home. Quality assurance needed development to ensure relatives, carers, and friends’ views of the service were ascertained. There was a health and safety policy in place and measures were taken to maintain a safe environment for residents. Staff had appropriate and updated training. To maintain safety, a hoist required servicing. EVIDENCE: The acting manager had applied to be the registered manager of the home. She was appropriately qualified and experienced, and was in the process of completing her NVQ4 in management. Quality assurance at the home required some development, so that carers, relatives, and friends could express their views on the quality of care offered to the residents. No questionnaires had been sent to them in 2005. Regular auditing of the service and provider’s monthly reports was in place. There was a development plan. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 20 There was a health and safety policy in place. Fire drills were carried out and the fire safety systems were serviced and checked regularly. A resident’s hoist had not been serviced within the required timescale. A range of training including moving and handling, first aid, health and safety, fire, infection control and adult protection was in place, and was updated on a rolling programme. Risk assessments were in place for the safe storage of hazardous substances, and a safe environment was maintained. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 21 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 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Burncross Road Score X 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 2 X DS0000002942.V254723.R01.S.doc Version 5.0 Page 22 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 2 3 Standard YA6 YA6 YA17 Regulation 15 12 13 16 Requirement All care plans and assessments on care plans must be dated and regularly updated The resident must be regularly weighed as required by the healthcare plan. To improve their diet, fresh food, fruit and vegetables must be used in the preparation of resident’s meals. Processed and convenience foods must be kept to a minimum. The administration of medication must be accurately recorded on MAR sheets. All medication must have the name of the resident for whom it is prescribed on it. Medication must be administered according to the instructions of the GP and the MAR sheet. MAR sheets must be kept with the medication. Damaged corridor areas must be redecorated. Damaged doorframes and skirting boards must be repaired and redecorated. (Timescales of 31/03/05 and 01/10/05 not met. The identified fire doors and emergency lights must be DS0000002942.V254723.R01.S.doc Timescale for action 01/05/06 01/04/06 01/05/06 4 YA20 13 01/04/06 5 YA24 23 01/05/06 6 YA24 23 13 01/04/06 Burncross Road Version 5.0 Page 23 replaced. 7 YA36 18 Staff must receive regular support and supervision. (Timescales of 01/06/05 and 01/10/05 not met). All staff must have a yearly appraisal. The quality assurance system must be developed to include the views of carers and relatives on the quality of care provided to residents. The identified hoist must be serviced as soon as possible. All hoists and other equipment must be serviced regularly. 01/05/06 8 9 YA36 YA39 18 24 01/06/06 01/06/06 10 YA42 13 01/04/06 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 2 3 Refer to Standard YA20 YA30 YA32 Good Practice Recommendations The medication cabinet should be kept tidy and medication should be easily accessible. The manager must obtain NVQ level 4 qualification in management and care. 50 of the staff team should have NVQ level 2 qualifications. Burncross Road DS0000002942.V254723.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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. 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