Inspection on 10/09/04 for Byars Care Home

Care Home For Older PeopleByars Care HomeCaythorpe Near Lowdham Nottinghamshire NG14 7EBAnnounced Inspection10th September 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Byars Care Home Address Caythorpe, Near Lowdham, Nottinghamshire, NG14 7EB Email address beckedgeltd@btclick.com Name of registered provider(s)/company (if applicable) Beckedge Limited Name of registered manager (if applicable) Verity Gay Hallam Type of registration Care Home No. of places registered (if applicable) 27 Tel No: 0115 966 3981 Fax No: 0115 966 3529Category(ies) of registration, with (number of places) Dementia (10), Old age, not falling within any other category (27), Terminally ill (2) Registration number C030000103 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984? Do additional conditions of registration apply? Date of last inspectionDate of latest registration certificate 10th March 2003 NO NO 30/01/04 If Yes refer to Part CByars Care HomePage 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 310th September 2004 10:00 am Sarah McIntyreID Code084187Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionMs V. Hallam Mr P. MabbottByars Care HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspectors Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with Conditions (if applicable) Providers Response Providers Comments Action Plan Providers AgreementByars Care HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the CSCI in respect of Byars Care Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Byars Care HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. The Byars is a two-storey building, in a rural setting offering care to 27 male and female service users with nursing needs. There are 21 bedrooms; 15 single and 6 double with ample bathroom and toilet facilities. A lift facilitates access to the first floor. There is a large open plan lounge, sun lounge and dining area. There is a small parking area to the front of the building. The gardens are small but very well maintained and well used. A fully trained team of nursing and care staff are employed and ensure that all aspects of service users health and social care needs are addressed. There are no restrictions on visiting and the home is well supported by both the local community and residents (past and present) families.Byars Care HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.)Byars Care HomePage 6 The inspection took place over one day and was carried out by one inspector. Three service-users were case-tracked in compliance with current Commission for Social Care Inspection, inspection methodology. It is clear from the evidence produced that the providers and staff team show a strong commitment to providing a high standard of care for elderly people. The service-users and relatives spoken with expressed a high level of satisfaction in the service. There are no requirements or recommendations arising from the inspection. Choice of Home (Standard1-6). 5 of the 6 standards apply. 2 of the six standards were assessed and both were exceeded. Three care files were seen during the inspection of the service. Each file contained a detailed assessment, which covers all aspects of need based upon the activities of daily living model including Eating and Drinking, Personal Hygiene, Mobility etc. The registered manager completes the assessment prior to the person moving to the home. Evidence provided during the inspection by reading care files, discussion with service-users and relatives and observation would support the ability of the staff team to meet the needs of service users admitted to the home. The registered manager is keen to ensure that the practices of staff in the home is evidencebased and based upon current research. Health and Personal Care (Standard 7-11). 4 of the 5 standards were assessed and all were exceeded. Each of the service-users case-tracked during the inspection had a plan of care to meet their assessed needs. Plans are based upon what is thought to be current best practice The care plans are detailed; this is especially so for those plans in respect of service-users mental health needs. The visitors spoken with on the day of the inspection stated that they were kept up-to-date in respect to the care of their relative. The evidence provided in the files seen as part of the inspection supports that service-users healthcare needs are identified and met. Evidence was seen of GP involvement and referral to hospital-based health services is sought where appropriate. Evidence was seen of attendance at outpatient appointments. There is a strong commitment to training within the ethos of the home and evidence was produced of staff at all levels attending training relating to continence, nutrition and tissue viability. The palliative care needs of one service-user case-tracked on the day of the inspection appeared to be appropriately met. The service-users file contained evidence of the involvement of the GP; evidence was also seen of the introduction of an appropriate pressure relieving mattress, the use of nutritional supplements and review of pain relief to ensure the persons comfort. The relatives spoken with, spoke highly of the care provided, they feel that they are kept abreast of the situation. Daily Life and Social Activities( Standards 12-15). 3 out of 4 standards were assessed all standards were exceeded An activities coordinator is employed within the home; on the day of the inspection this person was seen to be providing one-to-one activities with service-users. The providers publish a newsletter on a regular basis, which details forthcoming community events, social outings, entertainment and religious services. An invitation is extended to relatives and friends to join in the activities of the home. The relatives spoken with on the day of the inspection spoke highly of the activities provided. The relatives spoken with confirmed that they were able to visit when it was convenient to them. Service-users appear to be encouraged to join in activities in the local area and relatives are asked to support this where possible. An excellent varied menu is offered; the menu is predominantly made up of traditional dishes. A detailed assessment of food preferences and dietary needs is carried out on admission and these were seen in service-users files. The cook demonstrated a good Byars Care Home Page 7 knowledge of what the likes and dislikes of each service user and is able to offer an alternative where necessary. Complaints and Protection (Standards 16-18). None of the three standards were assessed Environment (Standards 19-26). 6 of the 8 standards were assessed all were met The home is located on the edge of a small village. The home is a conversion and extension of existing buildings. The exterior of the home is well maintained with mature gardens and parking to the front of the building. There is a ramped entrance to the home allowing wheelchair access. The interior of the building is very homely and agreeably decorated and the furniture is domestic in style. The communal space in the home is provided in one central area and although essentially one large space due to the conversion this space is divided into smaller more intimate areas, which seat between four and eight service-users in small groups. Large windows provide a view to the front and rear of the building. A range of accessible bath and shower rooms is provided in the home; those seen on the day of the inspection appeared clean and well maintained. Toilets are situated throughout the home. A lift provides access to the first floor and a stair lift is also provided. Adequate accessible baths and showers are provided in the home; hoists and grab rails are provided. Accommodation is provided in a mixture of single and double rooms; where double rooms are occupied fixed screening is provided to afford privacy. The rooms seen on the day of the inspection were clean and well decorated; with furniture that meets the minimum standards including a lockable facility. Staffing (Standards 27-30). 3 of the 4 standards were assessed and met or exceeded The duty rota provided as part of the pre-inspection information show that the levels of staffing over the 24 hour period and meet the expectations of the previous regulatory authority. Adequate domestic and catering hours are deployed. The providers have made a strong commitment to vocational qualifications with the majority of staff either holding or currently working towards a care qualification at either a level three or four; these staff are supported by two registered nurses who hold an assessors award. Evidence was provided to support that members of staff are provided with training opportunities related to their role in the home. Management and administration (standards 31 - 38). 4 of the 8 standards were assessed and all were met or exceeded. The Registered Manager is a first level registered nurse; she has completed a diploma in Nursing and is now working towards a degree in Nursing. The manager has completed the registered managers award. The training plan provides evidence that the manager frequently updates her knowledge of working with the service user group for whom the home provides nursing care. No health and safety issues were noted on the day of the inspection. Evidence was provided that maintenance and servicing of equipment and utilities in the home e.g. moving and handling equipment etc. Evidence was provided that the staff team have received training in relation to first aid, moving and handling, fire and other health and safety matters.Byars Care HomePage 8 Requirements from last Inspection visit fully actioned? If No please list belowNASTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report, which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Byars Care HomePage 9 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Regulation Standard * Requirement Timescale for actionRECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues, which should be considered for implementation by the registered Provider(s). The code in Standard is a cross-reference to the Standards described in full in the section Inspection Findings. No. Refer to Good Practice Recommendations Standard ** Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Byars Care HomePage 10 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling · Pre-inspection questionnaire · Records · Care plans / Care pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs) YES YES YES YES YES YES YES NO YES YES YES NO YES YES YES YES NO YES YES YES 3 4 0 YES YES YES YES 12 9 10/09/04 10.00 9.0Byars Care HomePage 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Care homes for older people have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 ­ Standard Exceeded 3 ­ Standard Met 2 ­ Standard Almost Met 1 ­ Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Byars Care HomePage 12 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities, and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide. Range of fees charged From (£) 337.00 To (£) 407.00Any charges for extras If yes, please state what the extras are:YES Toiletries, personal items and hairdressing 0 Standard met?Key findings/Evidence Standard not assessed during this inspection.Byars Care HomePage 13 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 4 Key findings/Evidence Standard met? Three care files were seen during the inspection of the service. Each file contained a detailed assessment, which covers all aspects of need based upon the activities of daily living model including Eating and Drinking, Personal Hygiene, Mobility etc. The registered manager completes the assessment prior to the person moving to the home. A number of risk assessment tools are used to determine nursing needs including; moving and handling, falls, use of bed rails, pressure area (based upon Douglas tool), nutrition and continence. Evidence seen on the day of the inspection supports that these documents are reviewed on a monthly basis. Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 4 Key findings/Evidence Standard met? Evidence provided during the inspection by reading care files, discussion with service-users and relatives and observation would support the ability of the staff team to meet the needs of service users admitted to the home, including those with a level of care needs, which may challenge services. The evidence provided by the registered manager would support that members of the staff team attend training appropriate to their role and are experienced in caring for elderly people. The registered manager is keen to ensure that the practices of staff in the home is evidencebased and based upon current research. Chiropody is offered on a six-weekly basis included in the fees. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Byars Care HomePage 14 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff, to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? Intermediate care is not provided in the home.Byars Care HomePage 15 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 4 Key findings/Evidence Standard met? Each of the service-users case-tracked during the inspection had a plan of care to meet their assessed needs. Plans are based upon what is thought to be current best practice e.g. those plans related to continence contained excellent background information relating to the types of urinary incontinence and management strategies to promote and improve continence. The care plans are detailed; this is especially so for those plans in respect of service-users mental health needs. There are several types of documentation in place, all contain evidence of monthly review of plans; however the registered manager explained that the documentation would be rationalised in order to provide a more consistent approach to the review of care plans. The visitors spoken with on the day of the inspection stated that they were kept up-to-date in respect to the care of their relative.Byars Care HomePage 16 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. No. of incidents where service users have been taken to Accident and Emergency during last 12 months No. of service users with pressure sores at time of inspection (from information taken from care notes) 1 04 Key findings/Evidence Standard met? The evidence provided in the files seen as part of the inspection supports that service-users healthcare needs are identified and met. Evidence was seen of GP involvement and referral to hospital-based health services is sought where appropriate. Evidence was seen of attendance at outpatient appointments. The manager is currently completing a BSc Honours Degree in Nursing and as part of this has undertaken modules relating to promotion of continence, evidence-based practice and tissue viability and effective healthcare for elderly people. There is a strong commitment to training within the ethos of the home and evidence was produced of staff at all levels attending training relating to continence, nutrition and tissue viability. Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 0 Key findings/Evidence Standard Met? Standard not assessed during this inspection.Byars Care HomePage 17 Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with, and examination by, health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 4 Key findings/Evidence Standard met? It was evident on day of inspection that all service users are treated with care and respect; staff were observed to speak in a respectful manner with service-users and showing understanding of that persons assessed communication needs. Staff team members were witnessed knocking on doors and discreetly taking service-users to the toilet. The relatives spoken with stated that members of staff consistently acted in this manner. Shared rooms have fixed curtain screening provided. All service users were called by their preferred term of address and this is documented in service-users records. Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 4 Key findings/Evidence Standard met? The palliative care needs of one service-user case-tracked on the day of the inspection appeared to be appropriately met. The service-users file contained evidence of the involvement of the GP; evidence was also seen of the introduction of an appropriate pressure relieving mattress, the use of nutritional supplements and review of pain relief to ensure the persons comfort. The relatives spoken with, spoke highly of the care provided, they feel that they are kept abreast of the situation. The relatives are offered drinks and feel able to get these themselves if they wish to; the relatives come and go as they choose and are made welcome. The relatives confirmed that they had been asked about their wishes.Byars Care HomePage 18 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 4 Key findings/Evidence Standard met? An activities coordinator is employed within the home; on the day of the inspection this person was seen to be providing one-to-one activities with service-users. The care files show that this individual records participation in one-to-one, group and social activities such as the reminiscence group, the activities coordinator carries out a review of participation on a three monthly basis. The providers publish a newsletter on a regular basis, which details forthcoming community events, social outings (on the19th August a boat trip was arranged from Colwick Marina), entertainment (provided on a fortnightly basis) and religious services. An invitation is extended to relatives and friends to join in the activities of the home. The relatives spoken with on the day of the inspection spoke highly of the activities provided. Posters advertising the forthcoming events are displayed prominently in the home. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences. 4 Key findings/Evidence Standard met? The relatives spoken with confirmed that they were able to visit when it was convenient to them; one relative spoke of staying quite late. Relatives stated that they could see their relative either in the communal areas or in their bedroom. It was evidenced on the day of inspection that visitors were made very welcome by staff, an invitation had been extended to all relatives and refreshments were served. Service-users appear to be encouraged to join in activities in the local area and relatives are asked to support this where possible.Byars Care HomePage 19 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet, which is suited to individual, assessed and recorded requirements, and that meals are taken in a congenial setting and at flexible times. 4 Key findings/Evidence Standard met? An excellent varied menu is offered; the menu is predominantly made up of traditional dishes. On the day of the inspection the lunch provided consisted of Salmon in Dill Sauce, Boiled Potatoes, Cauliflower and Carrots; a hot dessert is offered at lunchtime. Tea is a lighter meal e.g. quiche and salad, a buffet or cheese on toast. Meal choices are documented. The chef works closely with the service users to ensure that she meets their expectations. A detailed assessment of food preferences and dietary needs is carried out on admission and these were seen in service-users files. The cook demonstrated a good knowledge of what the likes and dislikes of each service user and is able to offer an alternative where necessary.Byars Care HomePage 20 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users legal rights are protected. Service users are protected from abuse.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple, clear and accessible complaints procedure which includes the stages and time-scales for the process, and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days Key findings/Evidence Standard not assessed during this inspection. 0 X X X X 1 X 0Standard met?Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Byars Care HomePage 21 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self-harm, inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists Key findings/Evidence Standard not assessed during this inspection. Standard met? YES 0 0Byars Care HomePage 22 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? The home is located on the edge of a small village. The home is a conversion and extension of existing buildings, which impacts on the building in relation to the width of corridors and size and shape of the rooms. The exterior of the home is well maintained with mature gardens and parking to the front of the building. There is a ramped entrance to the home allowing wheelchair access. The interior of the building is very homely and agreeably decorated and the furniture is domestic in style. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? The communal space in the home is provided in one central area and although essentially one large space due to the conversion this space is divided into smaller more intimate areas, which seat between four and eight service-users in small groups. There is a television area and a stereo is provided in another area. Large windows provide a view to the front and rear of the building. The dining area is small however adequate seating is provided.Byars Care HomePage 23 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? A range of accessible bath and shower rooms is provided in the home; those seen on the day of the inspection appeared clean and well maintained. Toilets are situated throughout the home. All rooms are clearly marked with hand-made ceramic tiles to provide a reference for service-users who may be confused.Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons, including a qualified occupational therapist, with specialist knowledge of the client groups catered for, and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? Members of staff were seen using mobility equipment during the visit and relatives confirmed that this is used when they are present. A lift provides access to the first floor and a stair lift is also provided, which has battery power in the event of a power failure. Adequate accessible baths and showers are provided in the home; hoists and grab rails are provided. Doorways into communal areas are of sufficient width to allow service users in wheelchairs access. Call systems are available throughout the home.Byars Care HomePage 24 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq. m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq. m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO NO YES 15 0 6 0 X XX X X X3 Key findings/Evidence Standard met? As an existing home compliance in respect of room sizes is not required. Four rooms in the home have a shared access; fixed screening is provided to afford privacy.Byars Care HomePage 25 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy, and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Accommodation is provided in a mixture of single and double rooms; where double rooms are occupied fixed screening is provided to afford privacy. The rooms seen on the day of the inspection were clean and well decorated; with furniture that meets the minimum standards including a lockable facility. Service-users have been able to personalise their rooms. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation and published professional guidance. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Byars Care HomePage 26 StaffingThe intended outcomes for the following set of standards are: · · · · Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours X X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff X X X No. staff hours allocated No. staff hours allocated No. of staff hours provided X X X X X X4 13 43 Key findings/Evidence Standard met? The duty rota provided as part of the pre-inspection information show that the levels of staffing over the 24 hour period and meet the expectations of the previous regulatory authority i.e. one registered nurse on duty at all times and four carers in the morning and three carers in the afternoon. Adequate domestic and catering hours are deployed.Byars Care HomePage 27 Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of the care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 6 50 4 Key findings/Evidence Standard met? The providers have made a strong commitment to vocational qualifications with the majority of staff either holding or currently working towards a care qualification at either a level three or four; these staff are supported by two registered nurses who hold an assessors award.Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 4 Key findings/Evidence Standard met? Evidence was provided to support that members of staff are provided with training opportunities related to their role in the home including; · moving and handling · tissue viability · communication · continence · fire training · mental health training · health and safety · aggression management · nutrition · food hygiene · basic first aid · infection control · protection of vulnerable adultsByars Care HomePage 28 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users financial interests are safeguarded. Staff are appropriately supervised. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 4 Key findings/Evidence Standard met? The Registered Manager is a first level registered nurse; she has completed a diploma in Nursing and is now working towards a degree in Nursing. The manager has completed the registered managers award. The training plan provides evidence that the manager frequently updates her knowledge of working with the service user group for whom the home provides nursing care. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Byars Care HomePage 29 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Standard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Standard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? No monies are held on behalf of service users. Families or representatives hold all finances and the manager approaches them if the service user needs some money.Byars Care HomePage 30 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? Standard not assessed during this inspection.Standard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met? No issues were noted in relation to the records seen on the day of the inspection. Both service-users and staff records are well maintained.Standard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? No health and safety issues were noted on the day of the inspection. Where risks are identified assessments are undertaken to minimise those risks. Work has been undertaken to the fire doors; the manager stated that they had worked closely with the fire officer to ensure safe evacuation. Evidence was provided that maintenance and servicing of equipment and utilities in the home e.g. moving and handling equipment etc. Evidence was provided that the staff team have received training in relation to first aid, moving and handling, fire and other health and safety matters.Byars Care HomePage 31 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateSarah McIntyre Rosamunde WillisReadSignature Signature SignatureByars Care HomePage 32 Public reports It should be noted that all CSCI inspection reports are public documents.Byars Care HomePage 33 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 10th September 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleByars Care HomePage 34 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESNOYESNote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required NOAction plan was received at the point of publicationNOAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planNONONOOther: enter details here NOByars Care HomePage 35 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Byars Care HomePage 36 Byars Care Home / 10th September 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000024633.V173967.R01© This report may only be used in its entirety. 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