Inspection on 11/08/05 for David Lewis Centre - Bryce House

This inspection was carried out on 11th August 2005.

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 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

David Lewis Centre - Bryce House 18/12/07

David Lewis Centre - Bryce House 05/02/07

David Lewis Centre - Bryce House 06/03/06

David Lewis Centre - Bryce House 08/11/04

David Lewis Centre - Bryce House 17/06/04

David Lewis Centre - Bryce House 16/02/04

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Ruskin Lodge

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Cornmill Nursing Home

Vitalise Sandpipers Centre

Sue Ryder Care Birchley Hall

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

CARE HOME ADULTS 18-65 Bryce House 3-4 Consort Close Bollington Macclesfield Cheshire, SK10 5FB Lead Inspector Sue Dolley Unannounced 14 July and11 August 2005 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 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 Stationary 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. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service David Lewis Centre - Bryce House Address 3-4 Consort Close Bollington Macclesfield Cheshire SK10 5FB 01565 640000 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Rachel@davidlewis.org.uk David Lewis Organisation Mrs Rachel Elizabeth Clare Care Home 11 Category(ies) of PD - Physical Disability (11) registration, with number of places Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Physical disability, 11 places registered. Date of last inspection 8th November 2004 Brief Description of the Service: Bryce House is a community-based service linked to the David Lewis Centre. Accommodation is provided for male and female service users between the ages of 18 and 65 years, who require support due to epilepsy, neurological problems, learning disabilities and other associated difficulties. Service users and staff members work towards addressing personal care needs, and independent living within the local community. The home is in the village of Bollington, approximately two miles from Macclesfield, within easy reach of local facilities such as shops, churches and public houses. There are adequate car parking facilities, and a garden with walkways and sitting areas is available for service users. Bryce House comprises two interlinked bungalows owned by a housing association. Service users accomodation consists of 11 single bedrooms; all of which have wash hand basins fitted. Communal space consists of two lounges and two kitchen/dining rooms. There is a utility room containing a washing machine and tumble drier, and an adequate number of bathing/shower/toilet facilities are available for service users. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 14th July 2005 over 8 hours to assess if service users’ needs were being met. A tour of the premises included all bedrooms and communal areas, bathrooms, toilets, laundry, and kitchen facilities. Several members of staff and most of the service users were spoken to and provided positive comments regarding the provision. What the service does well: What has improved since the last inspection? What they could do better: The monthly review details were out of date for one service user and a photograph to aid identification was not available on file for another service user. The minutes of service user meetings could be printed and either circulated to service users or displayed on the notice boards for service users to refer to. Staff members should sign the collective training record to indicate they have read and understood the confidentiality policy. Service users wishes concerning terminal care and death should be discussed and recorded. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 6 A range of necessary maintenance, and improvement works to the premises and renewal of the furnishings must be carried out to ensure national Minimum Standards are met. Many of the David Lewis Centre policies and procedures are currently under review and these are awaited by Bryce House. 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. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3 and 5 Information is provided to prospective and existing service users for them to make an informed choice about where to live. The admission process is well managed. Needs assessments are thorough and well written, ensuring that service users needs are accurately identified. The process of people moving into Bryce House is well managed to make sure individual needs are met and service users quickly settle into their new environment. EVIDENCE: The statement of purpose and service user guide, were updated in February 2005 and provide accessible, useful information to prospective and existing service users about the provision. The provision opened in 1994 offering new concepts of care to promotedcommunity integration for individuals with epilepsy and learning disabilities. The ethos of Bryce House is to actively encourage and support self- management, independent daily living and a community presence. The statement of purpose mentions skill development programmes for individuals identified for resettlement or rehabilitation. Several of the service users have gained many independence skills during their stay at Bryce House. Although they would like to move to a more independent and supported environment in the community the possibilities for progression to resettlement are limited due to lack of suitable provision. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 9 The majority of admissions to Bryce House are internal and received from the adult division of the David Lewis Centre. The assessments recorded within individual files are internal assessment documents. One external placement has recently been provided and a full assessment of needs had been undertaken. Examples of two care files were examined during the inspection and each provided thorough assessment documentation. The staff at Bryce House had developed an individual plan of care and essential lifestyle plan with each service user to address all care needs. Goals for the future had been identified and reviews of care were evident. One review of care needed to be updated and advice was given regarding this. Family carer’ interests and needs had been taken into account, subject to the service user’s agreement. Individual care programmes were in place for all service users, developed through person centred planning and living skills assessments had been undertaken to identify appropriate independence skills activities and to promote and develop independence within the home and community. Each care file provided a very clear pen picture in easy to read and organised text. Current areas of daily support required were well documented and defined. Medical intervention and support needs had been written in discussion with service users and signed by service users and their key workers. In discussion staff members demonstrated that they had a good knowledge of service users needs and circumstances and demonstrated that they individually and collectively have the skills and experience to provide the necessary level of care. Care staff had been provided with explanatory notes regarding various medical conditions to aid their understanding. Health and safety risk assessments had been completed as appropriate. The assessments were positively written and highlighted areas of independence and achievement. One care file did not contain a photograph of the service user to aid identification. See Recommendation 1. All service users have a licensee agreement with the Housing Association and have copies of these in an appropriate format. The licence charge for the occupation of the premises is shown and the total charge includes amounts attributable to rent, lighting, meals, furniture, water rates, heating, counselling/support and care services. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 10 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 standard(s) 6,7,8,9 and10 Service users are consulted about their care and support needs. They can access a range of healthcare facilities and are well looked after in respect of their health and personal care needs. Service users are supported to make individual decisions and choices and independence is encouraged. Confidentiality is maintained and staff members know when information can be shared. EVIDENCE: Service users are offered guidance and training in all areas of daily life such as cooking, washing, ironing, managing bank accounts, and making choices and decisions. The aim is maximise individual potential and to enable service users to live as independently as possible. Service users each have a named key worker who works with them to help them to identify and achieve goals. Care planning is carried out using Essential Lifestyle plans (care plans) and risk assessments. The service user’s key worker is responsible for co-ordinating his or her care plan, monitoring its progress, and for staying in regular contact with everyone involved in the service user’s care. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 11 The two care files checked were very detailed and provided much information regarding medication and money management, independent travel and shopping, and promoting health and wellbeing. Individual goals towards developing greater independence within the community were well documented and person centred planning, ensure service users were heavily involved in identifying their care needs and in planning the necessary support. Bryce House aims to meet and respect the individual choice and rights of all service users, and to promote self-determination in all aspects of decision making and risk taking. Staff members provide service users with information; assistance and communication support to enable them to make choices. Staff members were able to demonstrate how individual choices had been made. They had recorded instances when decisions had been made by others, and detailed why this had been necessary. Staff members within the finance department of the David Lewis Centre ensure that payments are made to the Housing Association and act as appointees for services users in relation to benefits. The majority of service users handle their own medication, personal allowances and bank accounts with support as needed. Service user meetings are frequently held and are well attended. Minutes of the meeting are recorded in a book, which is held in the office. The minutes could be circulated and made more accessible to service users. Recommendation 2. The meetings provide service users with a forum to express their views and a representative from the housing association had attended on a number of occasions to enable service users to express their concerns and to ask questions. Service users completed household tasks on a rota basis with the help of staff if necessary. Service users confirmed that they frequently have meetings and discussions regarding the general running of the premises and housekeeping tasks. Service users are consulted on all aspects of life in the home. They explained that there are individual and shared tasks. During the inspection service users were seen preparing the evening meals. Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions. Risks are identified, thoroughly assessed, reduced and well recorded. Risk management strategies are agreed, recorded in the individual plans of care and are kept under review. All service users have various degrees of epilepsy and following assessment are enable to take part in a variety of activities. The care files contained appropriate health and safety risk assessments. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 12 There is a confidentiality policy for Bryce House. All staff members have a copy of this in their individual files. Confidentiality is discussed during induction. The registered manager monitors compliance with the confidentiality policy and would take appropriate action in the event of a breach. Advice was given as not all staff had signed the recording sheet to indicate they had read and understood the confidentiality policy. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 13 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 standard(s) 12,13,14,15,16 and 17 Staff members enable service users to have opportunities to maintain and develop skills, which will aid their personal development and independent living. Service users are engaged in various leisure and social activities which, promote social interaction and individual interests. Service user’s rights are respected and they feel they receive sufficient support and are listened to. Staff members assist service users to choose, plan, and prepare meals. Healthy eating is promoted meals are enjoyed. EVIDENCE: Service users are supported to attend local colleges for continuing education. Courses attended are varied and help to promote personal development. Care files and timetables provided information regarding attendance at adult educational classes and recreational courses at various colleges. Some service users attend the centres day services They participate in sport and social activities on and off site and have voluntary employment opportunities. Staff and service users have the use of a mini bus, which is part of the David Lewis Centre fleet of vehicles. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 14 9 service users are able to access public transport and 1 service user is currently developing skills to travel independently. 8 service users are able to use a public phone without assistance and have mobile phones to aid communication. There is also a pay phone available for use. Bryce House welcomes all visitors, especially family and friends. There are no designated visiting times but if visitors stay beyond 10pm they are asked to use the communal areas of the house so that service users are not disturbed within their personal space. Service users confirmed that they are able to enjoy community facilities such as the cinema, library, shops, leisure centres, pubs, restaurants or theatre either on their own or with support from staff. Most service users are able to go out independently. All service users hold their own keys to both the main entrance and their bedroom doors. Hobbies and personal interests are encouraged and regular holidays are planned to suit individual preferences. Recently 4 service users enjoyed a holiday in Spain accompanied by 2 members of staff. Staff members have a close working and friendly relationship with service users and many positive interactions were observed. Both staff and service users confirmed Bryce House is a friendly and relaxed place. Service users are enabled to maintain links with family and friends. Staff members respect service users’ own personal space and enter bedrooms and bathrooms only with the individual’s permission. Everyone at Bryce House has responsibilities for housekeeping tasks, menu planning, shopping, cooking, cleaning rooms and common areas, undertaking laundry, and maintaining gardens. Service users are involved in cooking for each other with staff support. Service users pre select menus and alternative foods are always available. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 15 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 standard(s) 18,19 and 21 Service users are very well looked after in respect of their health and personal care needs and family carers are supported. Service users are closely monitored. Potential health problems are promptly addressed by the appropriate health care services. Staff members treat service users with respectfulness and courtesy and service users dignity and privacy is maintained. The care records did not include service users wishes concerning terminal care and death. It is important that these details are known and recorded. EVIDENCE: Service users are consulted about their care and support needs. They are actively involved in deciding what personal care they receive and all personal care is provided in private. Staff members provide sensitive and flexible support, to promote service users’ privacy, dignity and independence. All service users have an identified key worker. Key workers support service users with personal hygiene and in their selection of personal clothing and toiletries. Health and care needs are closely monitored and promptly addressed. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 16 Individual working records set out the preferred routine, likes and dislikes of service users who cannot easily communicate their needs and preferences. When it is difficult to meet the expressed wishes of a service user an independent advocate can be invited to join the care review team. All service users at Bryce House receive specialist care for their epilepsy from a multi- disciplinary team based at the David Lewis Centre. They meet with each service user every eight weeks to oversee the service user’s medical and social needs. Service users use local healthcare facilities and local GP practices and Macclesfield General Hospital provide medical and nursing support according to individual needs. The care files seen provided evidence of prompt referrals to appropriate specialists for dental treatment, optical and chiropody care. Service users also have access to the hydrotherapy facility at the David Lewis Centre. Service users retain, administer and control their own medication where appropriate and receive occasional assistance with medication when necessary. Staff members closely monitor the condition of service users on medication. They call in the GP if they are concerned about any change in condition that may be a result of medication, and prompt regular medication reviews. The placement agreements recognise that a service user’s medical condition could change to such an extent that they may require hospitalisation. Should a service users condition be considered terminal, it is hoped that they would be cared for at Bryce House. Not all care records provided evidence that service users’ wishes concerning terminal care and death had been discussed and recorded although the registered manager has made efforts to gain this sensitive information from service users and their relatives. See Recommendation 3. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 17 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 standard(s) 23 Arrangements are in place to protect service users and to respond to their concerns; to ensure they stay safe and are satisfied with the care. EVIDENCE: There is a written adult protection procedure for the home, and a copy of the local social services procedure. The procedures follow the latest Department of Health guidance ‘No Secrets’, a copy of which is available to staff for reference. All staff members except one had received training on the protection of vulnerable adults. At feedback to the inspection the registered manager confirmed that since the inspection the remaining staff member had also completed this training. Service users have access to their personal financial records and the finance department of the David Lewis Centre oversees the receipt of personal allowances. Service users have access to the Centre’s cash office and their own bank accounts to obtain their personal money and a list is kept of service users’ personal furniture and items within Bryce House. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 18 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 standard(s) 24,25,26,27,28,29 and 30 Repair, maintenance, renewal and redecoration work needs to be addressed to ensure service users have a well-maintained environment in which to live. EVIDENCE: The Northern Counties Housing Association provides the accommodation under a licensee arrangement with individual service users. The landlords are responsible for the maintenance of the building, and records are available in the home that identify any remedial action reported and dates of completion of remedial work. The premises are purpose built and suitable for the service user group. The two bungalows are linked via a doorway. Both bungalows share a communal laundry. Communal areas include a lounge, kitchen/dining rooms in each bungalow and there are shared gardens. The premises are in keeping with other housing in the local community. The service provider maintains fire risk assessments for the home. Bedrooms are of various sizes and shapes and provide at least 10sq. m of usable space. There is sufficient communal space to meet the needs of service users. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 19 Service users facilitated a tour of the premises. Discussions were held with most of the service users regarding a significant number of necessary maintenance works awaited. Service users had previously met with a representative of the Housing Association to express their concerns. A deterioration of the premises and the fabric of the building was noted, with several of the maintenance works itemised at previous inspections still outstanding. Service users and staff expressed their disappointment regarding the outstanding maintenance work and the registered manager had sent a letter of complaint to the Housing Association. The following problems were noted during the inspection: 7 of the bedroom ceilings and 1 shower room ceiling are badly stained with mould. 2 window handles and locks need repair. Pipe work beneath a bedroom sink needs re-sealing Some fitted bedroom furniture has ill- fitting drawers, loose handles and broken veneer. An exterior light was not working. The woodwork beneath guttering and near to a seating area is rotten in places and presents a hazard. These problems detract from the usual high standards within the premises and have previously been reported to the Housing Association. The moulding to the ceiling areas has worsened considerably and the deterioration has been noted over previous inspections. The roof area must be inspected promptly for possible leaks prior to the onset of winter weather conditions and the necessary redecoration work to ceilings must be completed to improve the environment within bedrooms. See Requirement 1. Throughout the premises there are sufficient toilets and bathing facilities. There is a specialist shower facility in each bungalow and service users have hand washbasins in their bedrooms. Bedrooms are personalised to suit individual preferences. One service user has recently requested that their bedroom be redecorated to a colour and style of their choice. The communal areas are well decorated and comfortably furnished. The kitchens and laundry areas are well equipped and the premises are kept clean. Service users participate in a cleaning rota and receive support from care staff to maintain their living environment. There are policies and procedures in place for the control of infection and to ensure standards of hygiene are maintained. Service users can be referred and assessed for specialist equipment to maximise their independence should this be necessary. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 20 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35 and 36 Staff members have clear roles and responsibilities and are supported and supervised to undertake their work. Staff members are approachable, flexible and motivated. They have the necessary skills to care for service users. EVIDENCE: Person specifications and job descriptions are available. Staff members were able to clearly describe their roles and responsibilities. Staff members are aware of their own limitations and know when it is appropriate to involve someone else with more specific expertise. In discussion with service users it was clear that staff members get to know and develop a good relationship with the people they support. A lot of interaction exists between staff and service users and staff members are able to meet needs in a highly supportive and flexible way, whilst encouraging independence. Staff members were approachable and comfortable with service users, staff are interested and motivated and have a good knowledge of the disabilities and specific conditions of the service users. The staffing rotas were checked and were satisfactory. Staffing levels can be adjusted according to varying needs. There is a minimum of 2 staff members on duty each morning and evening and the registered manager is supernumerary. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 21 The required staffing levels were met at this inspection. The staffing establishment consists of a registered manager, 6 senior care officers and 2 care officers. 8 of 11 service users are male. There is one male member of staff. Ideally the staff team should reflect the gender composition of service users. Currently the registered manager or other staff members are expected to provide assistance for the sole member of staff on waking duty, should any emergencies arise during the night. There are safety issues in relation to members of staff working alone. Should an emergency arise during the night the staffing situation could prove problematic. Recommendation 4. The records showed a wealth of training had taken place and was being planned. A training activity rota was seen for August and September 2005 and listed a range of available training opportunities including mandatory and specialist training. Staff members have been keen to undertake training to progress their knowledge, competence and skills. There was evidence of regular and pre-planned formal supervision for staff. Staff members have daily and ongoing support and handover briefings are held between shifts to ensure there is sufficient time to exchange current information and to ensure continuity of care for service users. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 22 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,39,40,41 and 42 The processes of managing Bryce House are open and transparent and service users feel they can approach the staff and management to discuss any issues. Service users interests are promoted and protected. Service users and their relatives feel supported. EVIDENCE: The registered manager has achieved NVQ level 4 in Management and Care, and has other relevant qualifications. Lines of accountability are clear within Bryce House and with the management and various departments of the David Lewis Centre. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 23 Managers from across the centre routinely undertake monitoring visits to Bryce House. Reports of these regular quality-monitoring visits were available to view. They provided evidence of delegates assessing against the National Minimum Standards and of them identifying action to be taken to address any shortfalls. The monitoring visits and records have helped to identify difficulties at an early stage and have brought about consistency in the management and recording across the registered provisions within the David Lewis Centre. Many of the centre wide policies and procedures are under review. A policy manager is in post and is undertaking the review process. Home records are very well maintained and securely kept. Service users can access their records and information held about them. They also have opportunities to help maintain their personal records. The registered manager receives advice and support in the field of health and safety from centre personnel. Care staff members have completed mandatory training programmes for moving and handling, first aid, and behaviour management. Risk assessments have been completed regarding the premises, and care staff members refer to these. The fire precautions record book was checked and was well maintained. There was evidence of appropriate fire safety training and of fire safety equipment checks undertaken. A current certificate of employers liability insurance was on display. The registered manager has undertaken to supply CSCI with evidence of recent portable appliance testing. Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 24 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 4 3 x 3 Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 x 2 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bryce House Score 3 3 x 2 Standard No 37 38 39 40 41 42 43 Score 3 3 3 2 4 3 x F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 25 No Are there any outstanding requirements from the last inspection? 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 26 Regulation 23 Requirement The premises must be of sound constuction and kept in a good state of repair externally and internally. Timescale for action 31.10.05 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. 2. 3. Refer to Standard 2 7 21 Good Practice Recommendations Ensure each care file contains a photograph of the service user to aid identification. Provide individual service users with minutes of service user meetings or display copies of minutes on notice boards to facilitate access. Ensure that service users wishes concerning terminal care and death are discussed, recorded and carried out.(This recommendation is repeated from the last inspection on 8th November 2004). The night time staffing level should be reviewed regularly and the night time on call rota should be reconsidered, to ensure service users needs can be met at all times and by a staff team that reflects the gender composition of the service users.( A similar recommendation was made at the last inspection on 8th November 2004). 4. 33 Bryce House F51 F01 S6673 Bryce House V231346 210605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Unit D, Off Rudheath Way Gadbrook Pakr Northwich Cheshire, CW9 7LT 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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