Inspection on 10/04/07 for Byrnhill Grove

This inspection was carried out on 10th April 2007.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Byrnhill Grove 12/10/06

Byrnhill Grove 23/01/06

Similar services:

St Vincents

The Cotswold Home

Newbeech House

Winton House

Rush Court

Hillyfield Rest Home

The Maypole Nursing Centre

The Briars

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

CARE HOMES FOR OLDER PEOPLE Byrnhill Grove Park Avenue Ventnor Isle Of Wight PO38 1LR Lead Inspector Neil Kingman Unannounced Inspection 10 April 2007 10:15 X10015.doc Version 1.40 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 Byrnhill Grove DS0000066063.V332282.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 Older People. 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. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Byrnhill Grove Address Park Avenue Ventnor Isle Of Wight PO38 1LR 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) 01983 852495 01983 539040 South Wight Housing Association Limited Mrs Christine Elizabeth Osborn Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12 October 2006 Brief Description of the Service: Byrnhill Grove residential care home provides care and accommodation for up to 16 older people. Mrs Christine Osborn manages the home on behalf of the providers South Wight Housing Association Ltd. The home is a purpose built property opened in 1987 and located in Park Avenue Ventnor, close to the park and within approximately a half mile of the town with its shops and amenities. The home is integral to sheltered housing accommodation and has shared communal facilities. Residents’ rooms are for single occupancy and have en-suite facilities. They are located on the ground floor and accessible to all the residents. Access to some of the supported housing flats is through the residential home. Communal areas are located at ground level and comprise a large lounge with vaulted ceiling, a smaller quiet lounge, a garden lounge and a dining room. Residents have access to communal bathing and additional toilet facilities. The home provides 24 hours staffing. Weekly fees are £434.96. The manager states that a copy of the home’s statement of purpose and brochure are provided to all residents or their representatives where applicable. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report details the results of an evaluation of the quality of the service provided by Byrnhill Grove and brings together accumulated evidence of activity in the home since the last key inspection on 12 October 2006. It also focuses on the home’s response to the requirements identified at the last inspection. During this inspection consultation with people who use the service was limited to those people in the home at the time of the site visit. A wider consultation took place at the last inspection and included written and verbal feedback from residents, relatives and visiting health and social care professionals. The responses from that consultation were very positive. Included in the inspection was an unannounced site visit to Byrnhill Grove by an inspector on 10 April 2007. The registered manager Mrs Osborn was on duty and available throughout the day. During the visit the inspector spoke with staff on duty, several residents as a group and others in the privacy of their rooms. In addition, there was an opportunity for the inspector to speak with a relative who was visiting the home at the time. The inspector toured the building with the proprietor and looked at a selection of records. What the service does well: What has improved since the last inspection? Many of the requirements identified at the last inspection have been met: • New equipment has been purchased and introduced to the home to help the minority of people with mobility difficulties. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 6 • The numbers of waking night staff have been increased from one to two to better manage peoples’ needs and provide increased security for the home. Individual risk assessments for people have been produced as required but would benefit from more detail. A system of regular recorded staff supervision has been introduced. • • What they could do better: • POVA first checks or Criminal Record Bureau disclosures on employees must be obtained before they start working in the home and having access to the people who use the service. Evidence of checks and other information set out in Schedule 2 to the regulation must be available in the home for inspection by persons authorised. People who use the service and staff would benefit from additional information being recorded on the care plans and risk assessments to provide consistency of care. • • 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. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. 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. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3 and 6 – People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Information about the home is provided to people who use the service to enable them to make an informed choice about whether the home is suitable for them. The manager ensures that their care needs will be met by undertaking a proper assessment prior to them moving into the home. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. EVIDENCE: Information South Wight Housing Association Limited has produced a statement of purpose for Byrnhill Grove, which has been updated to include reference to the fact that there is access to the sheltered housing accommodation via parts of the home. A copy of this document has been supplied to the Commission. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 9 The home has a brochure (service user’s guide), written in plain English, which basically tells the prospective resident about the home. Mrs Osborn confirmed that a copy is given to all prospective residents with the statement of purpose and terms and conditions document, in most cases before they move into the home. Pre-admission assessment People should know that their needs will be met when they move into a home. An important part of ensuring this happens is the pre-admission assessment process. It had been noted at previous inspections of Byrnhill Grove that this standard had been met. During this site visit the manager explained that while she always undertakes a pre-admission assessment of a prospective resident’s needs there had been no new admissions to the home for almost a year. The manager showed a good understanding of the importance of a preadmission assessment in the process of choosing the right home. Examples of assessments were available for inspection in residents’ files. Intermediate care People who live at Byrnhill Grove tend to be long term. The home does not provide dedicated accommodation for short-term intermediate care or specialised facilities for rehabilitation. However, respite care is provided if there is a room available. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s 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. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who live in the home have good access to healthcare services. While their health and social care needs are identified and met this could be better evidenced with more detail in their individual personal plans and risk assessments. People are protected by the home’s policies, procedures and practices for dealing with their medicines. The home ensures that staff respect residents’ privacy and dignity at all times, especially with regard to the arrangements for health and personal care. EVIDENCE: Care planning – The home has a system of care planning with an individual personal plan for each resident. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 11 We looked at a sample of three plans. The intention was to look at the outcomes for residents in general by assessing all areas of care for those sampled. The sample included the newest admission to the home; this person having moved in almost a year previously, a person with mobility difficulties, and one who had lived at Byrnhill Grove for several years and was largely self-caring. We noted the basic structure and format of the sampled plans to be very comprehensive. However, the information recorded by staff in plans and risk assessments was not consistently clear enough to evidence the quality of care provided. This was identified as and issue at the last inspection. Examples being, a person identified as needing support but no information about the type and amount of support needed, and a person deemed no longer at risk but no information as to when the situation had changed. We noted good practice in respect of one person who had experienced several falls. A risk assessment was in place and it was noted that several strategies had been tried to minimise the risk of further falls, including a visit to the ‘falls clinic’ for an assessment. This issue was discussed with the manager who recognised the shortfalls and made a commitment to review and update all plans. One resident was fully aware of her care plan and confirmed that she often discusses the content with staff. Health and access to care services The manager confirmed, and records evidenced the regular contact with GPs, optician, dentist and chiropodist. People spoken with said that the home was very quick to contact a doctor if they needed one and to arrange the various checks with the dentist and optician where applicable. During the site visit we had an opportunity to speak at length with a visiting relative who was very happy with the way the home took care of their relative’s healthcare. They said the home kept them informed of all important matters affecting their relative. Records showed and discussions with care staff confirmed that no residents were currently vulnerable to pressure sores. However, the manager and staff were very clear about what was required to ensure that that pressure sores did not develop. At the last inspection it was judged that some peoples’ needs were not being met during the night due to inappropriate staffing levels and lack of equipment. Since that time levels of waking night staff have been increased Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 12 from one to two and a review of equipment has been undertaken. To meet the current needs of the people who use the service, five new adjustable beds have been introduced together with a ‘standaid’ and hoist. Medication Medication is dispensed by means of a monitored dosage (blister pack) system by staff who have completed medication training, and deemed competent by the manager. The home has a policy and system to ensure residents’ medication is stored, administered and recorded safely. During the site visit we looked at the arrangements in place and noted medicines were stored under secure conditions and accurate records maintained, including those for the administration of controlled drugs. Privacy, dignity and respect The importance of treating people who use the service with dignity and respect is outlined in detail in the statement of purpose. Staff spoken with confirmed that the subject is covered in the induction training for new staff. On the day of the site visit we toured the building and spent time with residents in the communal areas and in their own rooms. There were opportunities to observe staff at work. Staff knocked before entering rooms and spoke kindly to people. All residents spoken with were full of praise for the staff and their approach to care. The visiting relative was also complimentary of the way staff treated people. Residents can use the facility of a portable telephone to make and receive calls. Several also have telephone installations in their rooms. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. 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. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Byrnhill Grove offers a flexible and varied service where choices and preferences are encouraged and supported. Activities are offered to suit the needs of the residents. Friends and family are made to feel welcome and can visit at any time. Residents’ nutritional needs are satisfied with a varied and balanced diet of good quality food. EVIDENCE: Routines and activities – The manager said that routines are flexible according to residents’ choices. Several are able to manage their own care and it was clear from discussions with people around the home that there are no institutional routines. People can come and go as they please, join in with the activities if they wish, or not as the case may be. The home’s statement of purpose provides information about social activities, hobbies and leisure interests. The aim is for people to carry on with existing Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 14 hobbies, pursuits and relationships that they enjoyed before moving into the home. Activities are arranged jointly for residents in the home and for those who use the sheltered housing service. This was seen by those spoken with as a positive, rather than a negative experience. On the day of the visit there was a bingo session in one of the communal areas attended by several of the residents. Others spent time in their rooms or in a social group in the quiet lounge. In discussions with one senior carer it was clear that a range of activities had been explored and out of all of them bingo was the only enduring favourite. However, there is a visiting entertainer, music and movement, discussion groups, coffee mornings and the occasional shopping trip and visit to places of interest. The manager said that several people enjoy their own company in the privacy of their rooms, a view supported by three residents spoken with. Peoples’ spiritual needs are well supported with a lay preacher who visits the home to take communion every Friday. Some attend the local church with their relatives. Visiting arrangements – Visitors are generally welcome at any time, a fact confirmed by the visitor spoken with. People can receive visitors in their own rooms, many of which are spacious with large seating areas. Any of the communal areas are suitable for visitors, in particular the quiet lounge offers privacy if required. Personal autonomy and choice – People were spoken with as a group in the lounges and some individually in the privacy of their rooms. All those spoken with were well able to express their views they all felt they were given choices regarding routines in the home, e.g., times of rising, going to bed, activities, meals, personal care etc. Residents are encouraged to bring with them pictures, ornaments and personal items for their room. During the tour of the building it was noted that some rooms showed a high level of personalisation, which reflected the residents’ individual tastes and preferences. One in particular regarded her room as her home and was proud of the way it was laid out and personalised. Special mention was made of her garden at the rear. The management of residents’ finances is covered later in the report but in a general sense they are encouraged to handle their own affairs as long as they are able. The manager confirmed that all residents were represented by someone independent of the home and that there was no requirement to access the advocacy service. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 15 Meals and mealtimes – Menus are arranged over a six-week cycle and show food to be varied, appealing and as one person put it, “plain home cooking.” We had an opportunity to observe residents and staff at lunchtime. The atmosphere in the dining room was very sociable and friendly with people who live in the home mixing with those who use the sheltered housing service. Staff were available to provide discreet support but little was required. Food served looked appetising and was well presented. All those spoken with paid complements to the chef. There is an emphasis on ‘meat and two veg,’ because, according to the manager that is what people prefer, although the chef’s curries on a Saturday are popular. We noted that drinks and light snacks were offered to residents through the day between meals. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. 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. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 - People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home treats residents’ complaints seriously and responds appropriately. While procedures for responding to suspicion or evidence of abuse are robust shortfalls in the home’s recruitment procedures place people at risk of abuse. EVIDENCE: Complaints The home has a policy and procedure for dealing with complaints, details of which can be found in the statement of purpose, and the service users guide given to all new residents or their representatives. Additionally, a copy of the complaints procedure is prominently displayed in the reception. At the last inspection this standard was judged to have been met. Residents and the visiting relative spoken with were clear that they would take any complaints if the had them to the manager. Adult protection The home has a written procedure for the protection of adults at risk, which follows local authority guidance. A copy of the referral procedure is prominently displayed in the manager’s office. The protection of vulnerable adults is covered in the NVQ training for staff, of which 38 are now qualified. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 17 In addition, specific Abuse Awareness training is included in the training programme for staff. As at the last inspection staff spoken with were very clear about how to recognise abuse, what to do, and the importance of reporting issues of concern without delay through the home’s whistle-blowing procedure. They confirmed that training was given. Staff recruitment is covered later in the report. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. 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. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 - People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The location and layout of the home is suitable for its stated purpose in providing a safe and comfortable environment for those who live and work there. Decoration and maintenance are ongoing. All areas of the home are kept clean, hygienic and there are no unpleasant odours. EVIDENCE: Environment Byrnhill Grove is a purpose built residential care home for older people. The home is located in Park Avenue, Ventnor and is only a short distance from the amenities and facilities of the main town. The home shares accommodation with a sheltered housing service whose service users occupy self contained flats on the first floor. People who live in Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 19 the residential home have rooms on the ground floor and share the communal facilities with those in the flats. An issue highlighted at the last inspection is that visitors to the first floor flats have access via the residential home, past bedrooms, bathrooms etc. This clearly has the potential to compromise the home’s security arrangements. Since that time the company has carried out a feasibility study in respect of alternative access to the flats and confirmed it’s findings in writing. The outcome is that such an arrangement would not be viable. It was considered that the greatest security risk was during the night as there was only one waking night carer on duty. The company has since doubled the night staff to two and has amended the home’s statement of purpose to include the fact that access to the sheltered housing is via the home. At this site visit we toured the building and noted the bedrooms to be spacious, well furnished and decorated. All rooms are for single occupancy and have an en-suite facility. Several incorporate sitting areas large enough for two armchairs and a sofa. The home has ample communal areas, which are furnished and decorated to a good standard. There are two assisted bathrooms with toilets and two separate toilets close to the communal lounge. People spoken with during the inspection made very positive comments about the environment, especially their own bedrooms. Cleanliness It was noted that all areas of the home were very clean, hygienic and free from unpleasant odours. The laundry room has wipe clean surfaces, an impermeable floor covering and is equipped with commercial grade machines for coping with high volumes of washing at the correct temperatures. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. 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 home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 - People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home are deployed in sufficient numbers, are trained and given the necessary skills and experience to meet the needs of the people who live there. However, the home falls short of the 50 ratio of NVQ trained staff and shortfalls in the home’s recruitment procedures place people at risk of abuse. EVIDENCE: Staffing levelsThe home employs sixteen care staff, domestic and catering staff. Staff rosters showed and the manager confirmed that three care staff are deployed during the day and evening. The manager works in a supernumerary capacity. On the day of the site visit there were twelve people resident in the home with three care staff and the manager on duty. Overnight there are two wakeful carers on duty. These staffing levels are considered adequate for the current needs and numbers of residents in the home. Both staff and the visiting relative felt that there are sufficient staff on duty. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 21 NVQ training – Records showed and the manager confirmed that currently 38 of care staff have achieved the NVQ at levels 2 or 3. A further six care workers are currently undertaking the training. When they are qualified this standard will be met. Recruitment There have been three new staff recruited to the home since the last inspection. As at the last visit there were no staff recruitment files available for inspection. The manager confirmed that they are held centrally by the company, which means that it was not possible to check that robust vetting procedures were being followed to ensure the safety of the people who use the service. Following a telephone call to the company’s head office the manager confirmed that the three new staff had commenced working in the home (albeit under supervision) without confirmation of the required security checks having been received. Staff training – The home has just introduced the Common Induction Standards for new staff as recommended by ‘Skills for Care’. The home now has computerised training records with a matrix, which records details of training achievements. This was available for inspection and showed that training includes: Manual handling Food hygiene First aid Health and safety Medication Abuse awareness The manager said that the system of identifying training needs has been reviewed and will shortly be improved by having a centralised system. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. 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 home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 - People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service live in a home where the registered manager is fit to be in charge, and has experience and qualifications to run the home and meet its stated purpose, aims and objectives. While quality assurance measures are in place to ensure the home is run in the peoples’ best interests, including safeguarding their financial interests their safety is compromised by the shortfalls in recruitment procedures. EVIDENCE: Management – The registered manager Mrs Christine Osborn has been in post for just over two years and has experience as the deputy manager of a larger care home Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 23 before joining Byrnhill Grove. She is a qualified Registered Nurse and is currently undertaking the training for the Registered Managers Award. In addition, she updates her knowledge, skills and competence with periodic training in care related subjects specific to the service provided by the home. Staff spoken with during the site visit confirmed that regular staff meetings and formal supervision sessions were taking place. They felt the home was well managed; staff morale was high and communication was good. Quality assurance – The manager gave examples and records evidenced the home’s approach to quality assurance, which includes: • • • • • • The quality assurance policy. Yearly residents satisfaction questionnaires, which are being expanded to include families and representatives. Regular in-house care plan reviews, with plans to have quarterly involvement with families and representatives. Regular visits from the responsible individual of the company who monitors the conduct of the home. Regular staff meetings and supervision sessions. Residents meetings at which minutes are taken and issues dealt with. Residents’ monies – As outlined earlier in the report residents have either a family member or representative to support them. The home provides a facility to safeguard monies or valuables on request. Currently only two residents use the facility, whereby the home makes purchases on their behalf. The system was checked and found to be in order, with receipts for purchases kept. Health and safety – The home has policies and procedures in place to ensure safe working practices in the home. A sample of records was viewed including accident records, fire alarm tests and public liability insurance all of which were in good order. Staff training records showed, and staff confirmed that statutory training is scheduled and updated in manual handling, first aid, health and safety and food hygiene. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 24 Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x x x 3 x x 2 Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 26 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 OP29 Regulation 19 • Requirement POVA first checks or Criminal Record Bureau disclosures on employees must be obtained before they start working in the home and having access to the people who use the service. Evidence of checks and other information set out in Schedule 2 to the regulation must be available in the home for inspection by persons authorised. Timescale for action 27/04/07 • Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 27 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 OP7 Good Practice Recommendations People who use the service and staff would benefit from additional information being recorded on the care plans and risk assessments to provide consistency of care. Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 Byrnhill Grove DS0000066063.V332282.R01.S.doc Version 5.2 Page 29 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!