CARE HOME ADULTS 18-65
Chester Berry 766 Chester Road Erdington Birmingham West Midlands B24 0EA Lead Inspector
Gerard Hammond Unannounced Inspection 9th & 10th March 2006 09:35 Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 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 Chester Berry DS0000016724.V286469.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 Adults 18-65. 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. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Chester Berry Address 766 Chester Road Erdington Birmingham West Midlands B24 0EA 0121 386 2290 0121 386 2290 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) Birmingham Institute for the Deaf Mr Steve Davis Care Home 5 Category(ies) of Learning disability (5), Sensory impairment (5) registration, with number of places Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 9th September 2005 Brief Description of the Service: Chester Berry is registered to provide accommodation, care and support for five people with learning disabilities and hearing impairment. The service is managed and staffed by Birmingham Institute for the Deaf, and Trident Housing Association owns the premises. The property is a large, detached period-style house situated on the main Chester Road in the Erdington area of Birmingham. On the ground floor is a large, comfortable lounge, a spacious kitchen with dining area, a small laundry, an activity room, staff sleep-in room, office, toilet and garage. Upstairs are five single bedrooms and separate shower and bathrooms, each with a WC. To the rear of the property is a very large private garden, with patio area and garden furniture and lawned areas with shrubs and flowerbeds. At the front of the house is a small fenced garden and limited off-road parking. The Home has its own vehicle, but the area is also well served by public transport. The shopping areas of Wylde Green and Erdington are both close by and include a wide range of local amenities. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second inspection of the current year, and was unannounced. The inspection took place over two visits. This report should be read in conjunction with the one written following the inspection completed on 03 October 2005. The Inspector formally interviewed the newly appointed Manager and saw all of the residents over the two visits. Direct observation and sampling of records (including personal files, care plans, previous inspection reports and safety records) were used for the purposes of compiling this report. A tour of the building was also completed. What the service does well: What has improved since the last inspection?
This service is currently in a state of transition. Both residents and staff are living against a backdrop of real and likely changes, and this inevitably produces some feelings of uncertainty. Proposals to develop the service have now moved forward into fairly advanced stages of planning, but final decisions
Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 6 have yet to be taken that will enable the position to be confirmed. It is hoped that this situation will be clarified in the near future. A new Manager has been appointed, but only came into post immediately prior to this inspection, and has had little time to address requirements made at the time of the last inspection visit. New systems for assessment and care management are to be introduced, and training has been scheduled to support members of staff to implement these measures effectively. The home’s staffing complement has improved, with new staff recruited to previously vacant posts. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office.
Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 5 Residents’ needs have been assessed, but statements of need should be reviewed and updated. Each resident should have an individual contract, as specified. EVIDENCE: Key Standard 2 was assessed at the last inspection, and was partially met. A requirement was made that, in view of proposed changes to the service, residents’ statements of need should be brought up to date. The newly appointed Manager has only just come into post. She is seeking to introduce new care management systems into the home, and the Inspector had sight of the proposed new format. It is anticipated that these will be implemented in due course. There have been no admissions since the last inspection visit. When the proposed refurbishment and changes to the service have been put in place it will be necessary to update the current Statement of Purpose and Service User Guide and to amend residents’ contracts as appropriate. There is an outstanding requirement that residents should all have an individual contract that complies with National Minimum Standard 5.2. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 Residents’ care plans require development, so as to reflect fully how support should be given, and to include personal goals. Residents are supported to take risks responsibly, but risk assessments need to be developed so that hazards are identified correctly. EVIDENCE: Key Standards 6, 7 and 9 were all assessed at the last inspection. Standard 7 was fully met and Standards 6 and 9 met in part. Requirements were made that care plans should be expanded to include sufficient detail to inform the reader exactly how support should be given. Care plans should also include residents’ agreed goals. It is important that the outcome for each goal set can be measured. Goals should be evaluated when the plan is reviewed. Care plans and risk assessments should be cross-referenced. A further requirement was made in the last inspection report that risk assessments also need development, so that hazards are correctly identified and that assessments inform care plans appropriately. As previously reported, there is
Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 10 evidence that staff have a positive attitude to supporting residents to take risks responsibly, so as to encourage personal independence and to enhance opportunities for learning and personal development. These requirements remain outstanding. However, it must be acknowledged that the new Manager has not been in post long enough to have had an opportunity to address these issues directly. As reported above, new care management systems are to be introduced, and conversations with the Manager demonstrated her awareness and understanding of what needs to change. As previously recommended, person-centred approaches should be adopted when carrying out the review and development of individual plans, in keeping with the aspirations of the Government White Paper “Valuing People”. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Key Standards 12, 13, 15, 16 and 17 were all assessed at the last inspection. All of these standards were met in full at that time. The Inspector was able to meet with a relative of one of the residents, who was visiting on the day of the inspection. She expressed her general satisfaction with the service, but indicated that she would like to see some more structured opportunities for activities. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Residents receive personal support in accordance with their needs and preferences. EVIDENCE: Key Standards 18, 19 and 20 were all assessed at the last inspection, and fully met. The attire and personal grooming of the residents provided evidence that they continue to receive a good standard of basic personal care. As previously reported, direct observations of interactions between residents and members of the staff team demonstrate that they are comfortable in each other’s company and enjoy a good general rapport. All communication is appropriately supported with sign language. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Key Standards 22 and 23 were assessed at the last inspection, and met in full. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Residents live in a house that is homely, comfortable and safe. Their home is kept clean and tidy and a good standard of hygiene maintained. EVIDENCE: Key Standards 24 and 30 were assessed at the last inspection and met in full. As previously reported, proposals to completely refurbish the home are now in the advanced stage of planning, and it is hoped this work will begin later this year. Staff and residents continue to do their best to make the house homely and welcoming. The home is kept clean and tidy and a good standard of hygiene is maintained. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 A current training and development plan is required to assess fully the competence, qualifications and training needs of the staff team. Residents are protected by general recruitment practice, but all records required by regulation must be maintained and available for inspection. Arrangements for formal supervision of staff need to improve. EVIDENCE: Key Standard 35 and Standards 33 and 36 were assessed at the last inspection. All these standards were partially met. A requirement to recruit to vacant posts has now been met. It is difficult to assess fully the competence and qualifications of the staff team without a current training and development assessment. This requirement remains outstanding from the time of the previous visit. The plan should show, for each person working in the home, all training and qualifications completed to date, highlighting any gaps (including refreshers). The plan should also clearly show when outstanding training is scheduled, and who is to deliver it. Staff files were sample checked. One person’s file contained only one reference. The Manager advised that files are currently being updated. It was noted that several do not include recent photographs, as required. However,
Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 16 proof of identity and CRB checks were on file and files were generally in good order. Records required by regulation (Care Homes Regulations 2001) must be maintained in respect of each person working in the home. The Manager is already aware that formal supervision of staff is not yet up to the required standard (a minimum of six times in any twelve-month period, pro-rata for part-time staff) and undertook to take action to address this. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 The home is generally well run. Reports of quality assurance and monitoring activity need to be produced, and demonstrate how residents’ views underpin service development. General practice promotes residents’ health, safety and organisation and recording of safety checks need to improve. EVIDENCE: Standard 38 was assessed at the time of the last inspection, and was fully met. Since then, but only immediately prior to this visit, a new Manager has come into post. She holds a social work qualification (Dip SW) and a BTech National diploma in Care. She is also qualified to CACDP level 3 in British Sign Language. She indicated that it is her intention to begin working towards the Registered Manager’s Award as soon as this can be arranged. The Manager has worked in the Organisation for several years, including periods of time working at Chesterberry. A completed application to register the Manager must be submitted to CSCI. Conversations with the Manager indicate that she is keen
Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 18 welfare, but to address issues in the home requiring attention, and to develop the service for the benefit of people living in the house. The Registered Provider must ensure that visits and reporting required under Regulation 26 (Care Homes Regulations 2001) are carried out at least once each month. Visits should be unannounced, and reports should be available for inspection. A report of quality assurance and monitoring activity should also be completed, and this should reflect how the residents’ views have underpinned service review and development. Sample checking of safety records confirmed that there are still issues with completing required safety checks on the fire alarm and emergency lighting systems and keeping full records. Checks have generally been done, but there are gaps in recording. As previously suggested, it would be helpful if these tasks were specifically delegated, so that people are clear whose responsibility it is to do the job. Some issues highlighted by the Fire Officer’s report (12 October 2005) remain outstanding. Also, the record of tests of temperatures at water outlets revealed significant variations. The Manager advised that these problems had been acknowledged, and are included in the schedule of work to be done when the refurbishment commences. Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X X 3 X 2 X X 2 X Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 20 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 YA2 Regulation 14(2) Requirement Timescale for action 31/05/06 2. YA5 5(1c) 3. YA6 15(1-2) 4. YA9 13(4a-c) Resident’s assessments of need should be updated so as to inform development of care plans. (Outstanding since 31 December 2005) Each resident must have a 30/04/06 contract that specifies the room allocated, terms and conditions of occupancy, the personal support, facilities and services provided, fees charged and the rights and responsibilities of both parties. (Outstanding since 30 April 2005 - Not assessed at this inspection) Care plans should be developed 31/05/06 as indicated in the main body of this report, to include specific detail about how support is to be given, to set goals with measurable outcomes and to be kept under review as required. (Outstanding since 31 December 2005) Risk assessments should be 31/05/06 reviewed and developed as indicated in the main body of this report, so that hazards are correctly identified and control
DS0000016724.V286469.R01.S.doc Version 5.1 Chester Berry Page 21 5. YA34 19 Sch 2&4 6. YA35 YA32 18(1c) 7. YA36 18(2) 8. 9. YA37 YA39 9 24 26 10. YA42 13(4a-c) measure included in care plans. Risk assessments should also be cross-referenced with the care plan(s) to which they relate, and vice versa. (Outstanding since 31 December 2005) Documents required by regulation (Care Homes Regulations 2001) must be maintained for each person working in the home and be available for inspection. A training and development assessment and plan for each member of staff, including all information indicated in the main body of this report, should be forwarded to CSCI. (Outstanding since 30 November 2005) All staff must receive formal, recorded supervision with their designated line manager at least six times in any twelve-month period (pro rata for part-time staff). (Outstanding since 31 March 2005) Submit a completed application form to register the Manager to CSCI. The Registered Provider must ensure that visits and reporting required under Regulation 26 (Care Homes Regulations 2001) are carried out at least every month. Reports should be available for inspection. Devise and implement a formal system for Quality Assurance and Monitoring and make reports available to interested parties. Reports should clearly demonstrate how residents’ views underpin service development. Ensure that testing of the
DS0000016724.V286469.R01.S.doc 31/05/06 30/04/06 31/05/06 30/04/06 31/05/05 30/04/06
Page 22 Chester Berry Version 5.1 11. 12. YA42 YA42 13(4a-c) 13(4a-c) temperature of water at all outlets is conducted every week, and an accurate record maintained. Remedial action should be taken to ensure that water temperatures remain within an appropriate range. Ensure that the fire alarm is tested every week and an accurate record maintained. Review the Homes fire risk assessment, and ensure compliance with the Fire Officers report (12 October 2005). 11/03/06 30/04/06 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 YA2 Good Practice Recommendations Introduce person-centred approaches into the review and development of peoples care plans, in keeping with the aspirations of the Government White Paper Valuing People. Number and index care plans and risk assessments, so as to facilitate easy access and cross-referencing. Delegate the tasks of conducting safety checks and maintaining records to named individuals, to ensure that members of staff know whose responsibility it is. 2. 3. YA6 YA42 Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Chester Berry DS0000016724.V286469.R01.S.doc Version 5.1 Page 24 - 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!
