Inspection on 23/01/06 for Byrnhill Grove

This inspection was carried out on 23rd January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Byrnhill Grove 10/04/07

Byrnhill Grove 12/10/06

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 Janet Ktomi Unannounced Inspection 23rd January 2006 12.30 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.V278619.R01.S.doc Version 5.1 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.V278619.R01.S.doc Version 5.1 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 539000 01983 853054 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.V278619.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th August 2005 Brief Description of the Service: Byrnhill Grove is a registered residential home providing care and accommodation for up to sixteen older people (aged over 65 years). All bedrooms are on the ground floor, are for single occupation and have en-suite toilet facilities. Lounges, dining room and access to the gardens are provided. Byrnhill Grove is a purpose built property opened in 1987 and located in Ventnor. There is an adjoining supported housing complex, 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. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the second unannounced inspection of this inspection year; the remaining core and a number of additional standards were assessed. The inspection was undertaken on a weekday and lasted three and a half hours during which a tour of the building was undertaken. Discussions were held with the manager, staff on duty and people living at the home. Residents stated that they enjoyed living at the home; the food was excellent, they liked the care staff and could discuss any concerns with the manager. Residents and staff stated they would recommend the home to a relative or friend in need of residential care. Care and other records and documentation identified in the report were viewed. What the service does well: What has improved since the last inspection? The manager has completed the registration process and is now registered with the Commission. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 6 What they could do better: The home does not have a statement of purpose, service users’ guide or provide contracts for service users. Service users or their representatives therefore have no written information confirming the services the home provides and their rights and responsibilities. Care plans were seen to contain relevant information, however there was no evidence that they had been reviewed. Care plans must be reviewed at least monthly and as needs change. Care staff must also record care given and a photograph of all service users must be held by the home. The inspector was concerned about the security of the home as visitors to some of the supported housing flats must pass through the residential home in order to reach the stairs to the flats. The residential home has no control over who may be passing through the home as the occupants of the flats can buzz open the front door. Should an incident occur there would be no way of knowing who had been through the home. A number of bedroom doors were seen to be wedged open, one with a door guard fitted was wedged open and the manager stated that the door guard was not working. Working door guards must be fitted to all bedroom doors and wedges must not be used. The lighting in the corridors and entrance to the residential section is not bright enough and could present a risk to service users with limited vision. Staffing records are inadequate to confirm that full recruitment procedures are undertaken and all staff have satisfactorily completed the required preemployment checks. Care staff do not have annual appraisals or supervision. These must be implemented. The insurance certificate was both out of date and contained the name of the housing association who previously owned the home, not the current proprietors. The weekly checks to ensure that the fire detection equipment is working have not been completed every week. Please contact the provider for advice of actions taken in response to this Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 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.V278619.R01.S.doc Version 5.1 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 and 4. The home does not have a statement of purpose, service users’ guide or contract for service users. The home must develop these documents and ensure that service users or their representatives have the information they need to decide if the home is appropriate and what services they can expect to receive. The home fully assesses prospective service users and the manager ensures that only people whose needs can be met at the home are admitted. Standard six is not applicable, as the home does not provide intermediate care. EVIDENCE: The inspector requested a copy of the home’s statement of purpose and service users’ guide. The manager could not supply these documents. The manager confirmed that these documents are not available in the home and not provided to prospective service users or their representatives. The inspector discussed with the manager the information that must be included in these documents. The home is required to develop a statement of purpose and service users’ guide, a copy of which must be provided to all existing service users, their representatives and to the Commission. Copies of these documents must be available in the home for prospective service users or their Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 10 representatives and supplied to prospective service users during pre-admission assessments. The inspector also requested a copy of the contract provided to service users. The home accommodates both social services and privately funded service users. The manager stated that service users do not get provided with a contract and was aware that this would mean that service users or their representatives would be unaware of services included in the price or their rights and responsibilities whilst living at the home. All service users or their representatives, whether funded by social services or privately, must be provided with a contract which clearly states the terms and conditions of living at the home. A sample copy of the contract must be provided to the Commission. The home has purchased a care planning process that includes assessment documentation. This was seen to have been completed for all service users. The care plan for the most recently admitted service user was viewed and the assessment information would indicate that the home was able to meet her needs. Discussions with the manager, who undertakes pre-admission assessments, indicated that she was clear about the extent of needs the home could meet and those it would not be able to meet. The assessment process is comprehensive and includes an assessment of personal care, physical health, mental health, mobility, medication etc. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 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 and 10. The service users’ health, personal and social care needs are set out in an individual plan of care. Care plans must be reviewed monthly and full records of care provided must be maintained. EVIDENCE: The home has purchased a care planning system that provides a comprehensive assessment, care planning and recording and reviewing system that meets all the required standards. Four care plans were seen during the inspection. The process contains a review section. This had not been completed. The manager must ensure that either she or the allocated keyworker review care plans monthly. The recordings of care provided were discussed with the manager and care staff. These would indicate that either recordings are not being fully completed or that service users are not being offered baths or changes of bed linen on a regular basis. The manager stated that there are allocated days for both these activities and that they do occur, however the recordings do not demonstrate this. There is a need to ensure that care provided is fully recorded by care staff. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 12 The inspector was able to speak with a number of residents. They confirmed that care staff treat them as individuals with kindness, respect and polite manners. Residents also stated that their privacy is respected. All bedrooms are for single occupation and have en-suite WC and washbasin. Whilst all personal care is provided behind closed doors many of the bedroom doors were open during the inspection. This could result in service users’ dignity and privacy being compromised as access to some of the warden assisted flats is via the residential home and past the bedrooms of some service users. People within the flats are able to buzz open the complexe’s main front door and the staff and manager of the residential part of the building are not able to fully monitor who is walking through the building. The proprietors need to consider how access to the flats may be changed to avoid people having free access to the residential home and vulnerable people living there. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15. Residents are helped to exercise choice and control over their lives. A varied nutritious balanced diet is provided. The manager aims to increase the range of activities offered to residents. EVIDENCE: The manager informed the inspector that the activities offered by the home were discussed in a recent residents’ meeting. Residents had identified that they would like quizzes, cards and games, craft activities and outings. The manager is now implementing these. The home does not have transport for outings and the inspector discussed options as to charities that might be willing to loan suitable transport. During the inspection most service users were in their own bedrooms, some watching television or resting. Activities will be reassessed during the next inspection. Residents have the opportunity to make choices as to where and how they spend their time, meals and times for getting up and going to bed. Care records included instances where service users had refused baths. Residents spoken with confirmed that they were able to make choices and that any requested were met by the care staff. Residents’ bedrooms are generally of a very good size and contained many items of personal belongings including furniture, pictures and ornaments. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 14 The inspector was able to speak with the home’s chef who confirmed that alternatives to the set meal are available and that budgets for food are flexible and sufficient to provide a wholesome diet. Residents stated that they liked the food provided and confirmed that they are able to make suggestions and request different items if they wish. The menu for the week of the inspection was seen and provided a varied diet. The home has a large dining room which people living in the warden assisted flats can also use if the wish to book a meal. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 15 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, 17 and 18. The home must provide residents with written information about the home’s complaints policy and procedure. Any complaints received must be fully recorded especially the date of the complaint and when the complaint has been resolved. EVIDENCE: The home has a complaints policy that is detailed on the hall wall at the entrance to the home. The home maintains a complaints book that was viewed. The most recent complaint had been appropriately recorded in the book by a member of care staff but no date had been noted or signature of the person making the record. The complaint had been investigated by the manager but again no date had been included to indicate when the investigation had been concluded. The home must fully record all details relating to a complaint; the name of the person who took the initial complaint and the date of the initial complaint and when the investigation was commenced and concluded. Recording options in respect of complaints were discussed and the manager is to consider how a more confidential system may be introduced. As previously stated the home does not have a service users’ guide therefore residents or their representatives have not been provided with written information about the home’s complaints policy. Residents must be provided with written information as to the home’s complaints procedure. Residents spoken with stated that they did not have any complaints or concerns and that they would speak to the manager or staff if they had any. The manager confirmed that all residents are registered to vote and would be supported to exercise their rights and participate in the civic process if they Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 16 wish. The manager stated that should there be a need for advocacy services she would contact the person’s care manager. The home follows the Isle of Wight Adult Protection policy and procedure with a copy available on the office wall. The manager stated that adult protection is included within induction and during NVQ training. Care staff confirmed that they had received training in respect of adult protection and identified that they would discuss any concerns with the manager. Due to the lack of records it was not possible to confirm that full recruitment procedures, including POVA and enhanced CRB checks, had been completed on all staff working in the home. The home does not become directly involved in residents’ financial affairs although does hold small amounts of personal cash for use by individual residents. The storage arrangements and records for this were assessed. All money is individually held within a locked safe. Full records of money spent are kept. Records indicated that money is appropriately spent on personal items. Residents also have a lockable facility in their own rooms. As previously stated 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. Care staff described instances when they have come across people walking around the home who are not connected to it (or the flats accessed through the home). The proprietors must consider how residents’ (and staff) safety can be better provided and reduce the ease with which people can walk into the home. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 17 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, 20, 21, 23, 24, 25 and 26. The home is modern and purpose built providing appropriate communal and private accommodation, however the inspector was concerned about security issues for staff and service users. The housing association must improve the lighting in parts of the home and ensure that essential maintenance is completed in a reasonable timescale. Door wedges must not be used and door guards must be fitted to all bedroom doors. EVIDENCE: The home was purpose built in 1987 and provides accommodation in sixteen single rooms, all of a good size, with en-suite toilet and washbasin. The home has several lounge areas 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 has access to garden areas that the manager confirmed are pleasant in warmer weather with gardeners provided Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 18 by the housing association. A large car park is provided with level access into the home. The residential home is located in a complex with warden assisted flats. The home has a 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. Individual flats have their own lockable front doors, however the bedrooms of the home are not routinely locked and many were seen to be wedged open. 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. The Housing Association must consider how the security and privacy of residents and staff may be improved and control maintained over who is in the home. As mentioned above a number of bedroom doors were noted to be wedged open, including one fitted with a door guard that the manager stated was not working. Wedges must not be used and appropriate arrangements made where bedroom doors are to be held open, approved by the fire officer. Parts of the home do not have natural lighting and are reliant on overhead electric light. These areas appeared dark and service users with vision impairments may be placed at additional risk due to inadequate lighting. The lighting in the corridors, lounge and entrance area which do not have natural lighting must be reviewed and adequate lighting provided. At the time of the unannounced inspection the hairdresser was using the lounge for hairdressing. The manager explained that the home had a hairdressing room, however this had not been available for the previous three months as the boiler was located in this room and had been leaking. The manager had requested the housing association to repair the boiler three months previously. Either the boiler had to be turned off, and the home would be without hot water and heating, or they would have to manage with a leaking boiler. It is unacceptable that the home have to cope with a leaking boiler for three months placing staff at risk of slipping if they enter the room to mop the floors. There is also the risk that in this time the boiler will fail and the home will be without hot water and heating. As mentioned above a door guard within the home was also not working. The housing association must improve the speed with which repairs are completed within 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 Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 19 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. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Appropriate numbers of suitably trained staff are provided to meet service users’ needs. The home’s recruitment procedures appear thorough however the home does not hold all the evidence to demonstrate that this is the case. EVIDENCE: Residents, staff and the duty rotas confirmed that there are three care staff and a cleaner on duty during the morning; three care staff during the afternoon and one awake staff at night with access to the sleep-in warden if required. The manager is available on call when not present in the home. A cook is also provided seven days per week and prepares breakfast and lunchtime meals. Residents stated that care staff answer call bells promptly throughout the day and night. Staff were clear that residents’ needs came first. Most of the staff employed at the home have done so for a number of years and stated that they get on well with each other. Care staff and duty rotas confirmed that the home’s own bank and existing staff cover additional shifts resulting from sickness or leave. Care plans and observation during the inspection indicated that most service users are not significantly dependent and therefore the above staffing numbers would appear to be appropriate to ensure all needs are promptly met. The home employs eleven permanent care staff. Five of the permanent care staff have at least NVQ level 2 in care with an additional one carer undertaking the course. Three more carers are registered to commence the NVQ level 2 and one senior carer is to complete a refresher course for the A1 assessor to Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 21 enable her to assess NVQs undertaken in the home. The manager confirmed that the proprietors, South Wight Housing, are good at funding training and that the home now uses Community Solutions for their NVQs. The recruitment process was discussed with the manager and the staff files were viewed in respect of recruitment documentation. The process described by the manager would indicate that an appropriate recruitment procedure occurs, however the documentation was not available in the home to confirm that all the necessary pre-employment checks had been undertaken prior to staff commencing work at the home. South Wight Housing Association has a personnel department that handles much of the recruitment process. Vacant positions are advertised via radio, local paper or word of mouth. Applicants complete an application form that is returned to the personnel department in Newport. These are screened and then sent to the manager who selects those for interview. Interviews are conducted at the home with the manager and at least one other person. Interviews comprise of set questions, the responses to which are recorded and scored so that a clear decision as to why someone has been appointed or not is evident. The successful applicants are notified initially by telephone and then via personnel with a letter. The personnel department then requests references and CRB checks. The manager had a list of staff from the personnel department that confirmed that they had undertaken a CRB check. However there were gaps on this list for a member of staff who had been employed at the home for a long period of time. The manager stated that she does not get copies of references or confirmation that a POVA first check has been completed by the personnel 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. All information as specified in Schedule 2 must be held in the home. All new staff have both corporate induction and an in-house induction provided by the manager. The induction checklist was shown to the inspector and this is signed by the manager and new staff member to confirm that it is completed. The checklist contains all the required areas that new staff should be made aware of. The manager and care staff confirmed that they receive plenty of appropriate training and that they are paid during training time. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36, 37 and 38 The manager, Mrs Christine Osborn, is now registered with the Commission. The manager is to consider how service user surveys may be implemented as part of the formal quality assurance process. The home would appear financially viable but must ensure that a current insurance certificate is displayed. The home must implement annual appraisals and formal supervision at least six times per year for all staff. Records are generally appropriately maintained and stored, however those in respect of care provided, care plan reviews, staff employment and fire detection equipment must be improved. The inspector considers the home to be a generally safe place however improvements in the delays in getting equipment repaired and consideration of the security of the home must be made. EVIDENCE: Since the previous inspection the registration process for the manager, Mrs Christine Osborn, has now been completed and she is registered with the Commission. The manager is a qualified nurse who has experience as a deputy Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 23 manager in a larger home prior to becoming the manager at Byrnhill Grove. The manager confirmed that she undertakes all the relevant core and additional training to meet PREP requirements. 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 had already identified many of the requirements made following the inspection. The manager holds monthly residents’ meetings, the typed minutes of which were seen during the inspections. Residents also stated that they have regular contact with the manager and would be able to discuss any concerns directly with her. Staff meetings are also held, again approximately monthly, with minutes available for staff unable to attend. The manager’s line manager undertakes Regulation 26 visits to the home and provides a written report for both the manager and the Commission. All residents have six monthly reviews with their care manger and relatives that also provide a form of quality monitoring. Discussions were held with the manager as to how service users’ surveys or questionnaires could be implemented as part of the quality assurance and monitoring process. The manger will consider options and this will be discussed during the next inspection. The home was full at the time of the unannounced inspection. The manager confirmed that the home has a high occupancy level. All indicators confirmed that the home is financially viable. The home’s insurance certificate is displayed on the hall wall. This was noted to be both out of date (by about five months) and to contain the name of the housing association that previously owned the home. The home must display a certificate confirming that it has the necessary insurance and supply a copy of the certificate to the Commission. As previously stated the home does not become directly involved in residents’ finances. The manger confirmed that she is not the appointee for any residents. The home does hold small amounts of personal cash for use by individual residents. The storage arrangements and records for this were assessed. All money is individually held within a locked safe. Full records of money spent are kept. Records indicated that money is appropriately spent on personal items. Residents also have a lockable facility in their own rooms. The home does not provide staff with an annual appraisal or formal supervision. The manger was aware that this must be implemented and confirmed that she will commence this process. Throughout the report concerns in respect of specific records have been raised. Records are stored appropriately with access only available to those who have a need of access. Fire detection equipment checks were viewed. These should be undertaken weekly and were done during the unannounced inspection. The records however indicated that these are not always taking place every week. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 24 The home must ensure that these essential checks are undertaken weekly. As previously stated the records in respect of recruitment and pre-employment checks, service users’ guide, statement of purpose, service user contracts, care plan recording and reviews, photographs of service user and insurance certificate were inadequate and must be fully available for inspection. All information in Schedules 1 (statement of purpose), 2 (information in relation to people working at the care home), 3 (records to be maintained in respect of each service user) and 4 (other records) must be maintained and available for inspection. 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. The home is not secure and staff are not aware of everybody who has access to the home. Lighting must be improved in parts of the home identified to the manager. The boiler had been leaking for three months prior to the inspection and door guards were either not fitted or not working resulting in bedroom doors being wedged open. Weekly checks of fire detection equipment had not been undertaken. All staff have undertaken training in manual handling, first aid, infection control and fire awareness. Infection control equipment is available at the home. Staff are provided in appropriate numbers, however it was not evidenced that all the required preemployment checks had been undertaken. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 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 1 1 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 3 18 2 2 3 3 X 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 2 3 2 1 1 Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP1 Regulation 4 (1) 4 (2) Requirement The home must produce a statement of purpose and supply a copy to all service users and the Commission. This also relates to standard 37 The home must produce a service users’ guide and supply a copy to all service users and the Commission. This also relates to standard 37 All service users must be provided with a statement of the terms and conditions of accommodation (contract). A sample copy must be provided to the Commission. This also relates to standard 37 Care plans must be reviewed at least monthly. This also relates to standard 37 The manager must ensure that care staff fully record care given to service users. This also relates to standard 37 The proprietors must consider how alternative access to the flats may be provided so that residential service users’ privacy and security are no longer DS0000066063.V278619.R01.S.doc Timescale for action 01/04/06 2. OP1 5 (1) 5 (2) 5 (3) 5 (1) (b) 01/04/06 3. OP2 01/03/06 4. 5. OP7 OP7 15 (2)(b) 12 (1)(b) 01/03/06 01/03/06 6. OP10 13(4)(a) 13(4)(c) 23(2)(a) 01/04/06 Byrnhill Grove Version 5.1 Page 27 7. OP16 22 (5) 22 (6) 8. 9. OP16 OP18 22 (4) 19 (1)(b) 10 11. OP19 OP19 23 (4)(c) 23 (2)(p) 12. OP19 23 (2)(b) 13 OP29 19 (1) (a,b,c) 14. OP34 25 (2)(e) 15. OP36 18 (2) compromised. This also relates to standards 18, 19 and 38 The manager must provide a written copy of the complaints procedure to every service user and to any person acting on their behalf. This also relates to standard 37 All complaints must be dated. This also relates to standard 37 The manager must ensure that all pre-employment checks are completed. This also relates to standards 37 and 38 Working door guards must be fitted to all bedroom doors. This also relates to standard 38 Lighting in the entrance area, corridors and internal lounge must be reviewed and brighter light provided. This also relates to standards 25 and 38 The housing association must ensure that maintenance is completed within reasonable timescales. This also relates 25 and 38 The manager must be able to demonstrate that all the required pre-employment checks (references, POVA First and CRB) have been undertaken. All information specified in Schedule 2 must be available for inspection. This also relates to standard 37 and 38 The home must display a current insurance certificate for the current provider. A copy must be sent to the Commission. This also relates to standard 37 Annual appraisals and recorded formal supervision at least six times per year must be provided DS0000066063.V278619.R01.S.doc 01/04/06 01/03/06 01/03/06 01/04/06 01/04/06 01/03/06 01/03/06 01/02/06 01/04/06 Byrnhill Grove Version 5.1 Page 28 16. OP37 23 (4)(c(v)) Schedule 3 17. OP37 for all staff. All fire detection equipment must 01/02/06 be checked weekly and a record maintained. This also relates to standard 38 The home must have a 01/02/06 photograph of all service users. 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 OP33 Good Practice Recommendations The manager to consider how service user surveys can be undertaken as part of quality assurance systems. Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 29 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. Extracts may not be used or reproduced without the express permission of CSCI Byrnhill Grove DS0000066063.V278619.R01.S.doc Version 5.1 Page 30 - 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. 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