Inspection on 28/07/05 for Burncross Road

This inspection was carried out on 28th July 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Burncross Road 08/06/09

Burncross Road 27/06/08

Burncross Road 08/06/06

Burncross Road 01/03/06

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 S35 1RZ Lead Inspector Carol A Makin Unannounced 28 July 2005 09:30am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Burncross Road Address 209/211 Burncross Road Chapeltown Sheffield S35 1RZ 0114 2571763 0114 571763 Diane.Sutherland@new-dimensions.org.uk New Era Housing Association Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Diane Sutherland (at present not registered) PC Care Home Only 13 Category(ies) of PD Physical disability (9) registration, with number LD Learning disability (13) of places Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: The home has a variation in place to accommodate an extra resident temporarily. Date of last inspection 19 April 2005 Brief Description of the Service: Burncross Road is a care home providing personal care and accommodation for 13 residents. The home is owned by New Era Housing Association Ltd and is situated at Chapeltown areas close to shops and other local amenities and on a main bus route. The home is purpose built and consists of two properties adjacent to each other. One is single story with accommodation for 6 residents and the second is built on two floors and at present accommodates 7 residents. All bedrooms are for single occupancy and one has an en-suite facility. There are pleasant garden areas that are accessible to residents, these areas are private and appropriate garden furniture is provided. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last inspection carried out on 19 April 2005 was an extra visit therefore a full report was not produced. The majority of requirements issues as a result of the last visit have been actioned. Requirements not actioned have been incorporated into this report. A variation application was submitted to increase the numbers of residents to 13 for a temporary period. This was agreed to with conditions that staffing arrangements were adapted and some refurbishment of a room was actioned. The conditions were checked during this inspection and were met satisfactory. What the service does well: What has improved since the last inspection? The manager has been appointed permanently and is to go through the registration process with the CSCI. Further experienced staff have been recruited to the home as part of the organisations review of services. Staff training has been updated and more is planned in the next few months to ensure staff have received all statutory training. Staff morale appears to have improved, one new staff member stated that they had been made welcome by the team and that they were all friendly and helpful. The trees behind the property, which drastically reduced the daylight into the home, had been felled. This had made the home much brighter and the seating area outside a much more pleasant area for residents to sit. The two dining rooms had been decorated and new fridge and freezer provided. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 6 The Regulation 26 visit that the provider must make to the home have been carried out regular. The report produced of these visits indicate that a thorough check on the service is carried out by the organisation to ensure that residents are well cared for and the home is well managed 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. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 5. Prospective residents are only admitted after a full needs assessment has been carried out to ensure that their needs can be met. Advocacy support is available for those who have no family to act on their behalf. EVIDENCE: A resident was recently admitted on an emergency basis. Consultation took place with the CSCI and appropriate action was taken to ensure that the admission was appropriate and measures put in place. This was successful so that the new resident and the existing residents experienced as little disruption as possible. Advocacy services are available and recent links have been established with a specific advocacy service that understands the client group’s needs. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9. Relatives act on behalf of the residents due to their limited abilities and lack of communication skills. Advocacy services are utilised for those with no one to act on their behalf. Risk assessments are in place for the protection of the residents. Staff enabling them to be as independent as possible within their understanding and capabilities supports residents. EVIDENCE: The residents at the home all have high dependency needs with limited communication skills. They are not able to participate or contribute to the decision making process that affects the day-to-day running of the home. Families are involved in the decision making process and advocates are sourced for those who have no family involvement. The residents are not able to take responsible risks due to their limited awareness and capabilities. Risk assessments are in place for each individual in their person centred plans. Generic risk assessments are in place to minimise the risks to the residents in the home environment and outside the home. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 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 standard(s) 1, 12, 13, 14, 16, 17. Residents are provided with and take part in activities within the home and community appropriate to their interests and capabilities. Thus providing them with stimulation and a good social life. Some residents are taken on holiday, which is part of their contract with the providers. Where it is assessed that a holiday away from the home would be detrimental to a residents wellbeing the providers do not compensate for this in a different way. Staff treat residents with respect and uphold their rights as an individual. Relatives are encouraged to join in the daily activities with the residents. EVIDENCE: Due to the high dependency of the residents at the home none are capable of seeking employment or continuing any educational training. Stimulation is provided by their involvement in day centres they attend, activities within the home and outings that the home organises. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 11 Regular outings take place to local facilities and they had recently been three trips to the theatre one of them to see the musical “Fame”. Some residents had been on holiday and a holiday abroad is being planned for others. Nothing is provided in compensation to those who are assessed as not being well enough to go on holiday, which should be part of their contract agreement. Staff were witnessed interacting and speaking appropriately and respectfully to residents. Residents can access the garden area, which is well laid out and is a pleasant safe area. Relatives are made welcome and one resident’s parents give a lot of their time to maintaining the garden area of the home. Residents are involved in the food shopping and meals are flexible to take in individuals needs. It was evident from observations that the staff knew the likes and dislike of each resident and catered accordingly. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 20. Residents choices for the styles and colours of their clothes is known to staff and action is taken to ensure that they are dressed in what they like which reflects their personality. Specialist equipment is sourced to ensure the residents physical needs are met. A key worker system is in place to maintain the continuity and support of the residents care. Policies and procedures are in place to ensure that medication systems are implemented that provides sufficient care and support for the residents health needs. EVIDENCE: Residents seen were dressed in clothes that were personal to them in their own personal style and colours. All were dressed appropriately, were clean and tidy and looked well groomed. Some residents have their own specialist chairs, which are specifically made to their size and disability. Key workers designated to each resident and advocates are provided for extra support for those without relatives to act on their behalf. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 13 Residents at the home do not have the capacity to be responsible for their own medication. Policies and procedures are in place to ensure that the staff administers medication appropriately. Training is provided for staff in medication administration. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 23. Not all staff have received mandatory training in adult protection. The manager confirmed that policies and procedures were in place to deal with physical and/or verbal aggression by a resident. The residents are protected by the policies, procedure and guidelines followed at the home. EVIDENCE: The home had a complaints procedure, which the inspector saw. It contained details of how to contact the CSCI to make a complaint, that complaints would be responded to in 28 days and that complainants would not be victimised. No complaints had been received at the home or by the CSCI. The home has a system to record ant complaints it may receive. 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’. Staff training records recorded that some staff had received training on adult protection. The manager confirmed that further dates were booked for this training. Policies and procedures were in place to deal with physical and/or verbal aggression by a resident. Physical intervention was used only as a last resort by the trained staff, protecting the rights and best interests of the residents and is the minimum consistent with safety. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26, 28, Residents live in a home that is clean, well maintained and homely. The décor and furnishings are in the main pleasant and the home has a comfortable homely atmosphere. A few areas were in need of re-decorating and the manager said that these were to be re-decorated shortly. One room had an unpleasant odour and the carpet was wet due to a new residents incontinence problem. EVIDENCE: Residents bedrooms were well decorated and furnished each reflecting their personalities. The dining rooms in both houses had recently been decorated and looked pleasant. The lounges are well furnished and look homely and comfortable. The paintwork on the corridors needs attention as they were heavily marked and looked unsightly. The seating area outside is pleasant extensive work had been carried out to make this a safe and pleasant area for residents to sit out. The building was clean on the day of the inspection, however one bedroom checked had an offensive odour. Laundry facilities were sited away from all food preparation and storage areas. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 35, 36. The staff spoken to said the management of the home had improved recently. One of the temporary managers has been successful in her application and is now the permanent manager. Staff treat residents with respect this was evident from interaction witnessed by the inspector. All new staff members receive induction within 6 weeks. Further progress has been achieved by staff in their NVQ qualifications. Staff supervision had not been given priority however the manager said that she plans to rectify this. Mandatory staff training is not all up to date that would ensure that the staff team are developed fully and provided with the skills to protect the residents and themselves from harm. EVIDENCE: There has been a change in management structures at the home, staff interviewed said that things were settling down in the home and all were working together effectively. One said that it had improved at the home since the new manager had been appointed and now they knew what was happening within the organisation things were better. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 17 Staff observed during the inspection demonstrated treating residents with respect and demonstrated that they had the skills and experience for the tasks they are expected to do. The manager is aware 50 of care staff in the home must achieve a care NVQ 2 by 2005, four staff has achieved their NVQ awards and a further ten are in the process of completing levels 2 and 3. Staffing levels on the day of the inspection did meet the agreed level. All new staff members receive induction within 6 weeks. The manager confirmed the programme meets National Training Organisation requirements and staff interviewed said it covered such things as safe working practices, the organisation and workers role and the needs of the resident group. Supervision sessions for staff are not as frequent as is required; the manager said that these are to be arranged shortly and would continue on a regular basis. Not all staff had received training in infection control; dates are booked to rectify this. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39, 42. The monthly report produced by the provider indicates that thorough systems are in place to check that the home is running effectively for the resident’s wellbeing. The health and safety of residents and staff is promoted by the systems in place to monitor the environment and maintenance of equipment. EVIDENCE: The provider’s carry out unannounced monthly visits and a report is produced that the CSCI receive a copy of. These reports have improved recently and now contain evidence of all areas that have been checked also action to be taken for any improvements where needed. The home does have a health and safety policy. Fire drills are carried out and the fire safety systems are serviced and checked regularly. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 19 The four staff interviewed confirmed they had had training in health and safety, moving and handling, fire safety, first aid and food hygiene. When the building was checked no fire exits were blocked, fire doors closed on their rebates and hazardous substances were securely stored. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 20 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 3 Standard No 22 23 ENVIRONMENT Score 3 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x 2 x 3 x x Standard No 11 12 13 14 15 16 17 3 3 3 1 x 3 3 Standard No 31 32 33 34 35 36 Score 3 1 1 x 1 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Burncross Road Score 3 x 3 x Standard No 37 38 39 40 41 42 43 Score 1 x 3 x x 1 x J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 21 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. Standard YA 14 Regulation 5, 16 Requirement Timescale for action 1 Oct 2005 2. YA 14 3. YA 23, 35 4. YA 24 Service users in long-term placements must have as part of their basic contract price the option of a minimum 7-day annual holiday outside the home, where it is assessed that they are not well enough to go then compensation must be given in place of a paid holiday. The previous timescale given for action of 31 March 2005 had not been met. 5, 16 Service users personal finances 1 Oct 2005 must not be used to pay for staff accommodation when escorting them on holiday. The previous timescale given for action of 31 March 2005 had not been met. 13, 18, 43 Staff must receive training in 1 Oct 2005 adult protection issues and be made aware/instructed of guidelines relating to POVA and Whistle Blowing policies and procedures. The previous timescale for action of 1 July 2005 had not been met. 23 Damaged corridor areas must be 1 Oct 2005 redecorated.Damaged door frames and skirting boards, must be repaired and redecorated. The previous timescale given for J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 22 Burncross Road 5. YA 26 23 6. YA 33 18 7. YA 33 18 8. YA 35, 42 13, 18 9. YA 36 18, 43 10. YA 37 8 action of 31 March 2005 had not been met. The offensive smell must be eradicated from the service users room.The carpet must be cleaned. Staffing levels must be reviewed and increased to reflect the higher dependency levels of the service users. The previous timescale for action of 31.3.05 had not been met. A review of staff’s competencies must be carried out to ensure that they have the skills and experience to deputise and take charge of the home in the manager’s absence. The previopis timescale of 1.6.05 had not been met. All staff must receive training in infection control. The previous timescale given for action of 31.3.05 had not been met. Staff must receive regular support and supervision. The previous timescale given for action of 1.6.05 had not been met. Progress must be made to ensure that the manager’s registration is progressed. The previous timescale given for action of 31.3.05 had not been met. 1 Oct 2005 1 Oct 2005 1 Oct 2005 1 Oct 2005 1 Oct 2005 1 Oct 2005 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 YA 37 Good Practice Recommendations The manager should put into place plans to ensure that she obtains NVQ level 4 qualification in management and care by 2005. J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 23 Burncross Road 2. YA 32 Plans should be put in place to ensure that a minimum of 50 of the staff team obtains NVQ level 2 qualifications by 2005. Burncross Road J55 S2942 Burncross Road V236457 28.07.05 UI Stage 4.doc Version 1.30 Page 24 Commission for Social Care Inspection 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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