Inspection on 27/06/08 for Burncross Road

This inspection was carried out on 27th June 2008.

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

Burncross Road 08/06/09

Burncross Road 08/06/06

Burncross Road 01/03/06

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 08/11/2008.

CARE HOME ADULTS 18-65 Burncross Road 209/211 Burncross Road Chapeltown Sheffield South Yorkshire S35 1RZ Lead Inspector Ian Hall Unannounced Inspection 27th June 2008 09:30 Burncross Road DS0000002942.V367156.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 Burncross Road DS0000002942.V367156.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. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burncross Road Address 209/211 Burncross Road Chapeltown Sheffield South Yorkshire S35 1RZ 0114 257 1763 F/P 0114 257 1763 debbie.johnson@new-dimensions.org.uk www.dimensions-uk.org Dimensions (UK) Ltd 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) Mrs Diane Sutherland Care Home 12 Category(ies) of Learning disability (12), Physical disability (9) registration, with number of places Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2006 Brief Description of the Service: Burncross Road is a care home providing personal care and accommodation for 13 people. The home is owned by New Era Housing Association Ltd and is situated at Chapeltown. The home is purpose built and consists of two properties adjacent to each other. All bedrooms are for single occupancy and one has an en-suite facility. There are pleasant garden areas accessible to people. The manager confirmed that the current bed fees at the home were between £300 and £1000 per week. Information about the home is available to people in the form of a Statement of Purpose and the Service User Guide. These are available from the home. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that people who use this service experience good quality outcomes. This was an unannounced key inspection carried out by Ian Hall, regulation inspector. Burncross Road was visited between the hours of 08:30 am and 12:45 pm on the 27th of June 2008. Senior carer Kelly King was present during this visit. As part of this visit we looked in detail at how people were protected from harm. Prior to the visit the registered manager had submitted an Annual Quality Assurance Assessment (AQAA) which detailed what the home was doing well, what had improved since the last inspection and any plans for improving the service in the next twelve months. Information from the AQAA is included in the main body of the report. On the day of the visit staff were observed interacting with people that live in the home. A tour of the premises was made and records relating to care and the running of the home were examined. It was not possible to formally speak to people at the home on the day due to their high support needs. However, the inspector was able to observe the care provided and interactions between the staff and people. What the service does well: Burncross Road provides a welcoming and safe home appropriate to the people’s needs. Staff had a close relationship with people living at the home and could describe individual needs in depth. Equality and diversity was promoted, each persons individual differences, likes and dislikes were known and respected. Opportunities were available to all of the people living at the home that took into account their individual needs. People living at the home had a written care plan so that their needs were identified. People’s health care was monitored and access to health specialists was available to maintain good health. Relatives could visit the home at any time, to maintain contact. Staff said that they worked well together. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 6 The health and safety, complaints and adult safeguarding procedures protected people. 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. Burncross Road DS0000002942.V367156.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 Burncross Road DS0000002942.V367156.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. The service provides people with detailed information to enable them to choose whether the home is the one for them. Detailed assessments ensure that people’s needs could be met prior to offering them a place. EVIDENCE: An information pack is available that provides details of the standard of care and services available at Burncross Road. This includes useful information about staff, their qualifications, visiting the home, choosing meals and how to raise concerns. We checked two case files. Each contained a detailed needs assessment; this included such things as daily living, personal care, health care, social interests and areas of risk when appropriate. The assessment formed the basis for the initial care plan. Whenever possible people had been encouraged to visit and spend time at the home so they could meet members of staff and other people living at the home. This was confirmed by written entries in the case files. Copies of contracts, social work referrals and assessments were available and kept in the case file. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People were treated with respect and supported to make some decisions about their lives and take risks as part of an independent lifestyle. EVIDENCE: Two care plans were checked both of which were detailed and of a good standard. The format in place detailed people’s individual needs including their life history, preferred routines and the ways in how they communicated. The care plans checked had been reviewed on a regular basis. The manager and staff had a good knowledge of people’s preferred routines, care needs and communication methods and were able to demonstrate how they encouraged people to make choices within their capabilities. People were unable to take responsible risks due to their limited awareness and capabilities. People’s files contained individual risk assessments including meal times, mobility and travel to minimise the risks to people both inside and outside the home. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live in the home have their social and personal care needs met in a way that respects their privacy and dignity. EVIDENCE: People had good opportunities to access appropriate activities. During the week several people accessed day centres within the community. Regular outings took place. The home has its own mini bus, which gave staff the flexibility to plan trips on a regular basis. As an example the staff said that recently the weather had been warm and that people had really enjoyed trips to Castleton and Clumber Park. Holidays for people were organised. At the time of the inspection two people were taking a holiday with the support of staff. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 11 Discussions with staff and observations demonstrated that the routines within the home were flexible. People were encouraged to make simple choices about their daily living activities for example when they rose and retired and how they wished to spend their day promoting independence and choice. People who had chosen to spend the day at the home were observed to be relaxing in the lounge areas with staff or spending time in the garden area. Menus were continuously reviewed to provide a healthy balanced diet. Meal times were flexible to meet people’s needs. The staff spoken to had a good knowledge of people’s likes, dislikes and dietary requirements. The care plans checked incorporated any risks, i.e. swallowing, that may be presented to people during meal times and detailed records of meals taken were maintained. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 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. 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 this service. People who live in the home have their health and personal care needs met in a way that respects their privacy and dignity. EVIDENCE: Plans of care were examined and found to be satisfactory and are reviewed at least every six months to meet people’s changing needs. The goals and objectives are agreed with each person and advocate if appropriate and then regularly monitored and reviewed. People were registered with a General Practitioner and were able to attend the health centre if necessary. Other health services such as dental, ophthalmic and chiropody services were available in the wider community with staff accompanying people to appointments if needed. Medication was securely stored to keep it safe. A sample of Medication Administration Records (MAR) was examined that were fully completed and up to date. There were no controlled drugs, and a sample of medication stocks checked corresponded with the records kept. All staff that administered Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 13 medication had received accredited medication training to make sure safe procedures were followed. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 14 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 good. This judgement has been made using available evidence including a visit to this service. People who live at the home and their representatives feel able to complain and are confident they will be listened to. EVIDENCE: Written information about how to make a complaint was seen in the service user guide. This gave contact details of the CSCI so that people could contact the Commission with any concerns. Records of all complaints made were recorded, and detailed the action taken by staff in response to the complaint. No formal complaints had been made about the home. The manager and staff had undertaken training in adult protection. They were clear about the steps to follow if an allegation was made or if they suspected abuse. Staff were aware of the different types of abuse. The adult protection policy and procedure was kept at the home and was included within staff induction training. People said that they felt safe at the home. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 15 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 this service. People were provided with a safe and comfortable home that met their individual needs. EVIDENCE: People’s bedrooms were all individually decorated reflecting personal choice. We were told that people were encouraged to choose colour schemes and furnishings within their capabilities. Corridor areas were light and bright with level access throughout the home. The buildings were well maintained with a good standard of cleanliness throughout. Externally the home has enclosed gardens with planted tubs and paved areas where seating was provided. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 16 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who live at the home are cared for by a group of staff who have been properly recruited, trained and are sufficient in numbers to ensure their needs will be met. EVIDENCE: Adequate numbers of staff were on duty in each of the 2 buildings to meet the needs of people living at the home. We were unable to examine staff recruitment files. Staff were able to confirm safe procedures were followed and protect people living at Burncross. All staff were provided with a job description and contract of employment. The staff team are stable team a number having been there for a number of years. Staff said that they had been provided with training. Updates in mandatory training had been prioritised so that staff skills were up to date. Most staff have achieved NVQ Level 2, and supervision is taking place. Annual appraisals are taking place to the overall benefit of people. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. 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. People live in a home that is well managed and takes into account their wishes about how the home is run. EVIDENCE: We saw that there was always a competent member of staff on duty at the home with advice and support readily available. Staff said the manager was approachable, very professional and they felt confident in her. The manager had a job description that clearly defines her roles and responsibilities and staff were aware of his role. Staff had received management supervision at regular intervals; this is needed to develop staff and monitor care practices. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 18 The home’s owners visit the home to monitor care and standards at the home. Management use a quality assurance system to measure standards of care and service provided. Questionnaires were used annually to seek the views of people and relatives. Regular meetings are held for staff and people who live at the home. These give people living at the home a voice and chance to say how the home should be run. People felt that their views and opinions were taken into account by the staff. The manager handles money on behalf of some people, account sheets were kept with receipts kept. A second person witnessed each transaction. Policies and procedures met the required standards. Records were mainly up to date and well ordered to ensure the best interest of people. No fire exits were obstructed and hazardous substances were securely stored. Statutory servicing and checks of equipment were complete. Risk assessments had been completed and were being reviewed regularly to maintain a safe environment. Fire safety records and other maintenance records were up to date. The manager had received training in the Mental Capacity Act. This training has not been provided for the staff; it is needed to ensure they are aware of the changes needed to fully protect vulnerable people at the home. Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 19 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 3 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 3 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 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 20 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. Standard Regulation Requirement Timescale for action 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 YA7 Good Practice Recommendations Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. Extracts may not be used or reproduced without the express permission of CSCI Burncross Road DS0000002942.V367156.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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