Inspection on 12/10/06 for Byrnhill Grove

This inspection was carried out on 12th October 2006.

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 10/04/07

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 Liz Normanton Unannounced Inspection 12th October 2006 09:40 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.V310057.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.V310057.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.V310057.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: Byrnhill Grove is a purpose built property opened in 1987 and located in Ventnor close to the park, within easy walking distance to town for those who do not have mobility problems. Byrnhill Grove is a registered residential home providing care and accommodation for up to sixteen older people (aged over 65 years) and is unique as it is integral to sheltered housing accommodation with shared communal facilities. The home provides an easily accessible environment, with all bedrooms situated on the ground floor, which are for single occupation and have en-suite toilet facilities. Access to some of the supported housing flats is through the residential home. The home is owned by the South Wight Housing Association and managed by registered manager, Mrs Christine Osborn. Weekly Fees: £434.96. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and focussed on what the Commission considers to be core standards for a care home for older people as defined in the Department of Health (DOH) National Minimum Standards and looked for evidence of compliance with regards to requirements made at the last inspection. Information was gathered from a variety of sources, which included data being sent to the Commission prior to the site visit, discussion with four service users and written feedback from six service users, one care manager, discussion with three staff, one relative, the manager and the viewing of staff and service users’ files. This information was then triangulated to access outcomes for people living at the home. The overall outcome was that the residents are very satisfied with the service provided at the home however there have been some changes to residents’ needs and these are not being met at night. The majority of requirements were met, however the reference to the open environment still remains an outstanding issue and needs to be addressed. The home is referred to as the extra care unit and is advertised as such and this was considered by the inspector to be a factual inaccuracy as it is in fact a registered residential care home. Some additional requirements have been made at this inspection. What the service does well: The home is purpose built with all bedrooms being single and providing spacious accommodation with en-suite toilet facilities. The home continues to provide a very comfortable and clean environment for fourteen residents, and up to eight day care users. The home is well decorated with tasteful and good quality furnishings. Residents are encouraged to bring their own furniture and personal belongings to make their bedroom feel homely. A small and well-trained staff group provides a high standard of care for those that live at the home. The manager maintains good systems and comprehensive records, which are regularly reviewed and updated. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 6 Residents were complimentary of the care provided at Byrnhill Grove and stated they would recommend the home to a relative or friend in need of residential care. What has improved since the last inspection? What they could do better: A small number of residents would benefit from the purchasing of high/low beds, which enables them to have greater independence in transfers and also enables staff to use the portable hoist, which is not compatible with existing beds. Provide sufficient waking night staff on duty, to meet the mobility care needs of residents. The manager should undertake individual risk-assessments of each resident. There was discussion with the proprietors and manager with regards to access to the supported housing flats through the residential home as the residential home has no control over who may be passing through, this situation cannot be rectified and will therefore continue to be a concern. In respect of this the home should take action to safeguard residents and staff. The Statement of Purpose and Service User Guide should be updated to inform prospective residents and their representatives of the access situation. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 7 Staffing records are inadequate to confirm that full recruitment procedures are undertaken and all staff had satisfactorily completed the required preemployment checks. Care staff do not have annual appraisals or supervision. These must be implemented. 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. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 8 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.V310057.R01.S.doc Version 5.2 Page 9 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 & 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The relevant information to inform prospective residents what they can expect from the service is now available and all residents are provided with a contract of terms and conditions.. Prospective residents will have their needs assessed prior to being offered accommodation. EVIDENCE: It was a requirement at the last inspection that the home develop a statement of purpose and service users’ guide and to provide a copy to residents and to the CSCI; this has now been met. One resident stated that it would be better in larger print as they are registered blind. It was also a requirement that residents be provided with an individual contract, which has been done. In discussion with the manager they explained that they are responsible for the assessment of prospective residents. The manager had undertaken a Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 10 needs assessment the previous day and had discussed the person’s needs with a senior member of staff as the person has short term memory loss and she wanted to be satisfied that the staff team could meet this person’s needs. Evidence of the needs assessment was viewed and was considered to be satisfactory. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Throughout the day residents’ personal care needs are being met, however four residents’ individual personal care needs are not being met at night due to inappropriate staffing levels and lack of appropriate equipment which compromises their welfare and safe working practices for the night staff. Residents’ general health needs are met with support from external health professionals. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Three care files were viewed and contained a photograph of each resident and a care plan, which had been drawn up using information from the needs assessment. Details in the care plans could be improved with much more detail being provided to enable the carers to provide consistency of care to the residents. The senior care staff are responsible for the reviewing of care plans and this is done monthly. In discussion with the manager they explained that Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 12 service users are not involved in the reviewing of the care plans. The files did not include risk assessments. In discussion with four residents they stated that they felt well cared for and described the carers as very nice and supportive however one stated that one member of staff was always in a rush and on one occasion had not responded to a request. In response to questionnaires sent out six were returned and all were satisfied with the care provided and described staff as helpful. In discussion with three carers they stated that they are expected to provide care to four service users single-handedly during the night shift although the residents have high dependency care needs and have been assessed as requiring two staff to assist in transfers i.e. from chair to bed, bed to commode, etc. All three were very worried that there was a serious accident, waiting to happen. They were also concerned about the health and safety risks to themselves as employees. In discussion with the manager they confirmed that they have approached South Wight Housing about the situation and have requested additional hours to employ an additional night staff and have been informed that there is not sufficient money in the budget for additional staff. It is evident that the care needs of these four residents is not being met during the night and this matter needs to be addressed. In discussion with a care manager prior to the inspection they felt that people were well cared for but that the care staff did not cope well with the changing physical needs of the clients and that the home did not have necessary equipment for people with mobility difficulties and as a result of this people have had to be moved on. The manager explained that they have asked for appropriate equipment and requested that three hospital beds be purchased for existing residents and have been told that there is not sufficient money in the budget to purchase these. Residents’ health care needs are written into the care plan and all are registered with a general practioner (GP) of their choice. There was evidence of GP visits to the home. A chiropodist visits the home every six weeks for those who require treatment. District nurses have close links with the home and at present are visiting at least three times a week to provide nursing care as required. One resident told the inspector “I now do my own dressing and the district nurse brings the dressings on a Thursday”. All residents were observed to look in good health. The home’s policy and procedure for the storage and administration of medication in general safeguards residents. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 13 Five members of staff are responsible for the administration of medication and have been trained in this area. Controlled drugs are stored in a locked cabinet. Each resident in receipt of controlled drugs has an individual record book. One carer administers the controlled drug and this is witnessed by a second carer and both sign the record. A senior member of staff explained that all prescribed medication is received monthly and the deputy is responsible for incoming medication and records all medication coming into the home. There was evidence that unused medication is returned to the pharmacy. It was noted that secondary dispensing was happening at the home. The senior staff member explained that this only happened occasionally at weekends for early morning meds to be given by the night staff. This matter was discussed with the manager who agreed to stop this practice and implement changes immediately. Six medication administration records were viewed at random and had been signed and there were no discrepancies. There were guidelines in place for the administration of non–prescribed drugs and records kept when these were administered. In discussion with four residents they confirmed that they always had their medication on time. There was evidence that one resident is responsible for taking their own medication. All aspects of personal care is done in privacy. Residents can meet their family and friends in private. Some residents have telephones installed in their rooms. There are systems in place to ensure that residents always wear their own clothes. Residents with capacity are responsible for opening their mail. In discussion with residents they stated that they always felt treated with dignity and respect. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Although a number of activities are available during the week more could be done to provide additional choice of activities for residents to partake in. Residents have contact with the wider community but like more opportunities to go out. There are opportunities for people to make choices about how they wish to live their life. Residents receive a healthy, varied diet, however agency cooks should be asked to provide meals cooked in a style preferred by the residents. EVIDENCE: Residents’ hobbies and interests are recorded on their individual care plans. There are no activities available at the home but residents can access activities in the communal room in the sheltered housing complex, which is integral to the home. Activities include bingo, movement to music, (which is facilitated by a resident) debating groups, social chats. A small facility has been Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 15 provided in the home where residents can purchase small items such as toiletries which is a provision which was requested by residents. There have been several outings this year with trips to Blackgang Point to take in the views and have locally made ice cream, a trip to Ventnor beach and Godshill. Written and verbal feedback from ten residents indicated that they would like more opportunities to go on outings and get out and about in the community. This was discussed with the manager who stated that they had been looking in to this matter and is trying to arrange outings fortnightly through RSVP who are voluntary agency. One resident had stated she would like to go to the park. As this is situated just over the road from the home it should not be too difficult to arrange. The majority of residents now require assistance to access the wider community and rely on their relatives and friends to take them out. There should be sufficient staff employed on duty to meet the needs of the residents and be available to support them outside if required. Residents are able to maintain relationships with relatives and friends and visitors are always welcome at the home. Residents are able to receive visitors in private. A hairdresser visits the home twice weekly and there is a separate hairdressing salon in the home. The residents were all observed to be well groomed. Day care provision is available for up to eight visitors. Communion is provided in the home once a month and 3 residents go out to church with friends or relatives. Residents are able to make choices on how they wish to lead their lives. Outings are advertised in the reception and residents can choose to go out. The menu is on display in reception and residents are asked what they would like by staff. At lunchtime residents were observed having different meals from each other. Residents are able to choose how they wish to spend their time during the day. Some residents were observed choosing to stay in their rooms whilst others had gone to attend the exercise class. Although the staff communication book indicates that there is a routine in taking people a drink at half past six and a breakfast tray by 07.30 staff, residents and the manager confirmed that people can have a lay in if they so desire and that the routines have come about due to most residents being early risers rather then this being a regime which is implemented by the home. The inspector spoke with the cook who explained that meals were planned around residents’ likes but that the majority would like meat and two veg every day. The cook does provide alternative dishes to provide variety. At this inspection the lunchtime meal was a choice of chicken curry with rice or chicken casserole with mashed potato and vegetables. The meals looked Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 16 appetizing and a good portion was served. One resident who had chosen curry said, “I could eat that meal over again it was lovely.” Residents who returned questionnaires stated that the quality of meals provided had deteriorated since the last inspection. This was discussed with the manager who confirmed that the home has been experiencing some difficulties as the cook has been on long-term sick leave and they have had to employ agency staff that have different cooking styles. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 17 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. The integral design and layout of the home and sheltered flats leads to people having access through the home who are not accounted for and as a result of this residents and staffs safety and welfare is compromised. Evidence of robust recruitment practices must be made available for inspection. EVIDENCE: A requirement was made at the last inspection for the manager to provide a written copy of a complaints procedure and supply this to residents. A complaints procedure has been implemented and residents have details. The procedure on making complaints is also on display in the reception. There have been no formal complaints since the last inspection. Residents have used the residents’ meeting as a forum for them to raise issues about the change in quality of meals provided. The home follows the Isle of Wight Adult Protection policy and procedure with a copy available on the office wall. One allegation has been made since the last inspection and the investigation is ongoing. The home has followed procedures to safeguard residents. Two of the three staff interviewed have Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 18 attended adult abuse awareness training and all three knew how to use the home’s “whistle blowing” procedure. At the last inspection the issue was raised that access to some of the sheltered flats is via the residential home and the staff are not able to control who is walking through the home. This could place residents at risk especially at busy times of the day when staff are occupied in personal care tasks with service users or at night when one staff is within the home. A requirement was made for the proprietors to consider alternative access to the flats. In discussion with the manager she explained that the matter was raised with South Wight Housing Association and their Health and Safety department has stated that it would not be possible to provide alternate access. There were no recruitment records available in the home to evidence that robust recruitment practices take place. The manager explained that she had no responsibility for recruitment, as this was done by South Wight Housing Association Human Resources Department. The manager stated that she has liaised with the human resources department and explained that evidence is required in the home but has been refused this due to the Data Protection Act. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home compromises the safety of residents and staff due to the nature of it being open plan. Improvements could be made to secure the residential home as a separate entity without preventing residents from accessing communal spaces in the sheltered housing complex if desired. EVIDENCE: The residential home is located in a complex with warden-assisted flats and is referred to and known by staff and residents as the extra care unit. The home has a concierge door entry system. People wishing to visit somebody in the flats can use a call system at the main door direct to the flat. The person in the flat can then unlock the front door to the complex from their flat. This then allows the visitor free access to the entire complex including the residential home. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 20 Individual flats have their own lockable front doors, however the bedrooms of the home are not routinely locked. A number of flats are located above the residential home and access is via the residential home, past bedrooms, bathrooms etc., through one lounge and up a flight of stairs. Staff within the residential home do not have control over who enters the home. This compromises the safety, security and privacy of people living in the residential home. Staff may also be placed at risk. The layout of the home is quite spread out therefore staff may not be readily available in all areas. In discussion with the manager and proprietors the inspector was informed that it is not possible to provide separate access and that the residents of the home benefit from the daily social intercourse with tenants of the sheltered housing. There have been no issues raised by the residents with regards to the access issue. As access through the home will continue to be an outstanding concern South Wight Housing Association must consider what action could be taken to improve the security and privacy of residents and safeguard residents and staff. Doorguards have been fitted to all bedroom doors and some residents had chosen to have their doors propped open. The home has a quiet room, atrium (lounge area) and a large dining room shared with people living in the warden, assisted flats. Appropriate bathrooms, including one with a Parker bath are provided. Bedrooms viewed contained items personal to their occupants including furniture, pictures and ornaments. All bedrooms have an emergency call bell system. The home was clean and comfortable and provided pleasant surroundings. Residents have easy access to the gardens and a large car park is provided with level access into the home. The home employs domestic staff responsible for cleaning throughout the home. At the time of the unannounced inspection the home was noted to be clean with no unpleasant odours. All staff have infection control training and supplies of disposable gloves etc. are available. Laundry facilities are appropriate for the size of the home. Residents’ clothing is labelled to ensure that they are wearing their own clothing and laundry is returned to rooms in individual containers. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are sufficiently trained, skilled staff on duty during the day to meet the needs of residents however residents’ welfare is being compromised by the lack of appropriate staffing levels on night shifts to meet their assessed needs. There is no evidence available to demonstrate that robust, recruitment practices are being undertaken by South Wight Housing association. EVIDENCE: The home currently employs a manager, deputy manager, twelve carers, two cooks and cleaner. This is an established staff group with a mix of skills, experience and qualifications. Due to long-term sickness the home has had to use agency cooks. The home is also having to use agency and bank staff to cover for a staff member currently suspended from duty pending adult protection enquiry. Duty rosters evidence that there are three staff on duty on a morning and afternoon, one member of staff on each shift holds a position of senior. The manager works 35 hrs per week in a managerial capacity and is available to cover care shifts and catering if required due to staff absences. At the time of Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 22 the unannounced inspection there were three staff on duty in the morning and the afternoon. The number of staff at night reduces to one wakeful night staff. As mentioned earlier in the report the care needs of four residents have changed leading them to require two carers for transfers therefore there are insufficient staff on duty at night to meet care needs. In discussion with the night staff they stated that they are also responsible for responding to calls from tenants in the flats and have to leave the residential care home to wake up the sleep-in staff on duty in the warden assisted complex. The pre-inspection questionnaire provided prior to the unannounced inspection indicates that five care staff have completed National Vocational Qualifications (NVQ) in care at level 2 or above. Since the last inspection a staff member with NVQ level 2 has left the home, reducing the numbers to 35.71 of the staff team being qualified. There were no recruitment records available in the home to evidence that robust recruitment practices had taken place for the three most recently employed staff. The manager explained that she had no responsibility for recruitment, as this was done by, South Wight Housing Association Human Resources Department. The manager is therefore dependent on the personnel department to screen references and ensure that CRB and POVA First are completed. Systems must be put in place that ensure that all new staff have completed the necessary checks before they commence employment and that the manager has copies of references and confirmation of POVA First and CRB available for inspection in the home; this should include reference numbers. All information as specified in Schedule 2 must be held in the home. In discussion with the manager she explained that she has liaised with the human resources department and explained to them that evidence is required in the home but has been refused this due to the Data Protection Act. The manager demonstrated that she understood what format recruitment procedures should take and knew what documentation should be available for inspection. There was evidence that new staff had received induction training on commencement of employment and in discussion with the manager they explained that the induction process is usually completed within six months or sooner dependant on staff capacity for learning. There was evidence of staff training in staff files with certificates of attendance in situ. Training certificates were also on display in areas of the home. South Wight Housing Association has a budget for staff training and is committed to developing staff skills. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 23 Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 24 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a competent manager. There are some areas which require improvement, which are detailed in the report. EVIDENCE: The manager is a qualified nurse who has experience as a deputy manager in a larger home prior to becoming the manager at Byrnhill Grove. She has now managed Byrnhill Grove since February 2005. In discussion with the manager she explained that she is not responsible for managing any of the home’s budgets and that on occasion this situation has hindered her. It was believed by the inspector that this situation would have a direct impact on the Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 25 manager’s ability to implement improvements and prevent them from increasing staffing levels to meet residents’ changing needs. The manager is currently undertaking NVQ level 4 in management. She has also attended a ‘women into business’ course to develop her own learning needs. The manager has also attended adult abuse awareness training and dementia care training. Residents and staff stated that the manger is approachable and that the home is a happy place to either live or work in. The manager was aware of the things the home needs to improve and has complied with the majority of requirements made at the last inspection. As well as managing the home the manager is the service co-ordinator for the sheltered housing accommodation this additional responsibility does have an impact on her time and as a result she has not implemented annual appraisals or formal supervision of staff as required at the last inspection. The manager has developed a supervision matrix with the deputy and seniors being responsible for the supervision of the staff team but this has yet to be implemented. South Wight Housing Association is re-developing staff appraisals and replacing these with annual personal development plans. The home has quality assurance systems in place, which include monthly residents’ meetings, monthly staff meetings, Regulation 26 visits from a representative of South Wight Housing and yearly questionnaires. In discussion with a number of residents they confirmed that they feel listened to and requests are acted upon. At the last inspection the home was displaying an out of date insurance certificate, this has now been replaced with a current certificate, which expires on the 29/09/07. There was evidence that electrical equipment is routinely checked annually. There are no risk assessments in place for individual residents and there is now risk-assessment of the potential hazards inside or outside the home. Lifting equipment is serviced six monthly. The boiler has now been replaced and a tender to contract a company to improve lighting within the home as identified at the last inspection has been sent out. In discussion with the manager they explained that residents have responsibility for the management of their own finances. She has responsibility for withdrawing monies from three residents’ bank accounts and takes a signed consent form provided by the resident to allow her to do this on Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 26 their behalf. Any monies kept in safe- keeping are locked in a secure facility and records and receipts are kept of financial transactions. The health, safety and welfare of service users and staff is generally promoted and protected, however there are some concerns in respect of this already identified in the report. All staff have undertaken training in manual handling, first aid, infection control and fire awareness. Infection control equipment is available at the home. There has been an improvement of the checking of fire alarm systems with weekly checks now being undertaken however there is still a weakness in this area as on several occasions records indicated that fire alarms had only been checked three times a month instead of four. The manager agreed to designate a second person to be responsible for the checking of the fire alarm systems. There was evidence that the cook takes regular checks of fridge/freezer temperatures twice a day however there were gaps in recoding. The cook explained that this was down to agency staff that do not undertake this procedure. There was also evidence that agency staff are not probing the heat of food and this matter has been raised with the manager and all agency staff are told to do this. Staff are not provided in appropriate numbers to meet the care needs of residents at night and night staff raised concerns with regards to using moving and handling equipment on their own when a person clearly needed the support of two carers. The manager is aware of the situation and has raised the matter with the South Wight Housing who believe the current staffing ratios are sufficient and have explained that there is not sufficient budget for additional staff. It was not evidenced that all the required pre-employment checks had been undertaken. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 27 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 3 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 2 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 2 2 x x x x x x 3 STAFFING Standard No Score 27 2 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 2 Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 28 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 OP7 Regulation 12 (1) (a) 13 (4) (c) & (5) 18 (1) (a) Requirement You are required to provide appropriate equipment for the provision of care for residents identified as having mobility difficulties. You are required to ensure that staff are employed in sufficient numbers at night to meet the assessed needs of the residents. This also relates to Standards 27 and 38. You are required to undertake individual risk-assessments for all residents. The manager must ensure that all pre-employment checks are completed and that evidence of robust recruitment practices are held on staff files. This also relates to Standards 37 and 38 Timescale for action 28/01/07 2. OP7 30/12/06 3. 4. OP7 OP18 12 (1) (a) 13 (5) 19 (1)(b) 30/12/06 30/12/06 5. OP18 12 (1) 5. OP19 23 (1) (a) You are required to develop and 28/02/07 implement an action plan to better safeguard the residents and staff in relation to the access arrangements within the home. The manager must amend the 28/02/07 Statement of Purpose to inform DS0000066063.V310057.R01.S.doc Version 5.2 Page 29 Byrnhill Grove 6. OP29 19 (1) (a,b,c) prospective residents of the fact that access to the sheltered flats is often used by relatives and friends who pass through the home. The manager must be able to 30/12/06 demonstrate that all the required pre-employment checks (references, POVA First and CRB) have been undertaken. The proprietor must ensure human resources provide to the manager that information specified in Schedule 2, which must be available for inspection. This also relates to Standard 37 and 38 Recorded formal supervision at least six times per year must be provided for all staff. 30/12/06 7. OP29 19 (1) (a,b,c) 8. OP36 18 (2) 30/12/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP7 Good Practice Recommendations Staff and residents would benefit from additional information being recorded on the care plans to provide consistency of care. Byrnhill Grove DS0000066063.V310057.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Southampton, Portsmouth and Isle of Wight Ground Floor Mill Court Furrlongs Newport, IOW PO30 2AA 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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