Inspection on 18/12/07 for David Lewis Centre - Bryce House

This inspection was carried out on 18th December 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

David Lewis Centre - Bryce House 05/02/07

David Lewis Centre - Bryce House 06/03/06

David Lewis Centre - Bryce House 11/08/05

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

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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 David Lewis Centre - Bryce House 3/4 Consort Close Bollington Macclesfield Cheshire SK10 5FB Lead Inspector Julie Porter Unannounced Inspection 18 December 2007 15:30 David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 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 David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 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 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) Rachel.Clare@davidlewis.org.uk www.davidlewis.org.uk David Lewis Centre Mrs Rachel Elizabeth Clare Care Home 11 Category(ies) of Physical disability (11) registration, with number of places David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th February 2007 Brief Description of the Service: Bryce House is a community-based care home run by the David Lewis Centre. The people who live in the home are aged over 18 and need support because they have epilepsy, neurological problems, learning disabilities and other associated difficulties. The home is in the village of Bollington, approximately two miles from Macclesfield, within easy reach of local facilities such as shops, churches and pubs. Bryce House is made up of two interlinked bungalows owned by a housing association. There are 11 single bedrooms. Spaces that are shared by the people who live there include two lounges and two kitchen/dining rooms. There is a utility room with a washing machine and tumble drier, and there are enough bathrooms and toilets for the number of people who live in the home. Outside, there is car parking space and a garden with walkways and sitting areas. Information about The David Lewis Centre’s Bryce House including fees and charges and copies of the most recent inspection report can be acquired by contacting the centre’s administrative staff on 01565 640000 or the registered manager. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced visit to this service took place on 18 December 2007 and took 5 hours. Further information was obtained and feedback was given to the manager of the service on the telephone on 03 January 2008. One inspector carried out the visit. The visit was just one part of the inspection. Before the visit, the manager of Bryce House was asked to complete a questionnaire to provide CSCI with up to date information about the home. CSCI questionnaires were sent out for people who live in the home to fill in to find out what they think of the home. Other information received since the last key inspection was also reviewed. During the visit, various records were looked at a tour of the premises was carried out. The inspector observed how residents and staff were working together. A number of residents and staff were spoken with. They gave their views and these have been included in this report. What the service does well: What has improved since the last inspection? Further improvements have been made in the way in which residents’ medication is supplied. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 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 David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information is available regarding individuals’ needs before they move to the home and visits are arranged so that they know that their needs can be met at the home. EVIDENCE: Since the last inspection two people have moved to the home from the main site of the David Lewis Centre situated in Warford, Alderley Edge. A wealth of knowledge and information was available about these two people, as they have been lived at the main centre site for many years. Both have been asking to move away from the centre for a significant time. One person had the opportunity to spend time during the summer living in a house in Macclesfield. One common care file was checked at the visit and a plan was seen regarding one persons’ move, which included short visits and overnight stays that took place over a two-week period. The records showed that the person had moved in on 26 November 2007, and a license agreement was seen between the resident and the housing association that owns the house. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are involved with all aspects of planning their care so that they get the care/support they expect. EVIDENCE: One person’s care plan/common care file was checked at the visit. It included information about the persons’ likes and dislikes. There was also information about the person’s wish to move away from the main centre, something that has now happened. One of the person’s goals was to change jobs and they told us that this had also changed recently. During the period of moving from one home to the other, some risks had been assessed relating to cooking, travelling and showering. However the risk assessment relating to self- medication did not accurately reflect what was actually happening and care must be taken to up-date the records following the move. We were told that this would be dealt with as a matter of urgency. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in the running of the home and in activities, which they choose so they can keep busy and keep up their skills and interests. EVIDENCE: This is an exceptionally busy household and preparations were being made for Christmas at the time of the inspection visit. During the visit people were returning from work or college. Two residents were involved with cooking the evening meals in the kitchens at either end of the home, with varying degrees of support from staff. Residents were seen planning the Christmas menu and shopping lists. One person was going out for the evening to the pub with work colleagues, one person was going out with friends from church and someone was packing to go on holiday to the sunshine with their family. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 11 An invitation to stay for tea with four residents was accepted; this was a social occasion with opportunity to discuss life in the home. Everyone spoke enthusiastically about living in the home and they all clearly regard it as home. One person who had recently moved to the home said he had to do more, like cooking and cleaning, and he enjoyed living here. On a CSCI questionnaire that was returned, on resident told us that they would “like to move on to a small house or bungalow in the Macclesfield or Bollington area”. The manager told us that the David Lewis organisation is looking at the possibility of this happening. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health of the people who live at the home is monitored so they stay well and receive the care/support they need. EVIDENCE: The routines at the home are flexible and the people who live there are able to decide how they spend their time. They can choose who they want to help them, what they want to wear, when they get up and when they go to bed. None of the people who live at the home has a problem with mobility and at the time of the visit, specialist equipment was not needed. All the residents are registered with a doctor (GP) and dentist. Care plans for two residents that were checked during the inspection visit showed that other health care professionals from the David Lewis Centre are involved with their care. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 13 There is a medicines policy and procedure for the home to make sure that the people who live there get their medicines as prescribed. Staff give out the medicines in the home or residents manage their own medicines if a risk assessment shows this is safe. The medication administration record (MAR) sheets had been filled in correctly and staff had all received training about medicine administration. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is an effective complaints process that residents know how to use so they know they will be listened to and staff receive appropriate training to ensure that people are protected from harm. EVIDENCE: Eight of the people who live at the home completed questionnaires to tell us what they thought about it. They all confirmed that they would know who to speak to if they weren’t happy with anything in the home or their care. During the evening meal, people told us that they were all confident that staff listen to them and that they knew what to do if they thought they weren’t being listened to. The complaints log was inspected; it showed that there had been two complaints since the last inspection and both had been resolved. Adult protection procedures are in place and include a “Whistle Blowing Policy”. Staff have to report any suspicions or allegations of abuse directly to the David Lewis Centre’s social work department so that appropriate action can be coordinated and monitored. Bryce House have not made any adult protection referrals since the last inspection. We were told that all staff have now completed the adult protection training. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Delays in responding to the fire officer’s report and delays in taking action to repair the fabric of the building may be putting the residents of the home at risk of harm. EVIDENCE: The landlord of Bryce House is Northern Counties Housing Association and the people living there have license agreements. The housing association is responsible for the maintenance of the building. Records are available in the home that identify requests for action to be taken and dates for the completion of any remedial work. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 16 The last inspection report states, “Bedroom doors had not been upgraded to meet the recommendations of the fire officer as detailed in inspection reports dated 4 April 2005 and 6 April 2006. Action must be taken to address the fire officer’s recommendations and bring the home up to the appropriate standard without any further delay. This will ensure that residents and staff are protected in the event of a fire in accordance with appropriate standards.” The fire officer visited the home on 02 July 2007 and the report states, “All fire doors should be fitted with an intumescent seal and cold smoke seal”. Information received from the home identifies that this relates to two doors the storeroom door and the laundry door. Information showed that the David Lewis Centre’s Health and Safety officer completed a fire risk assessment on 02 November 2007 and safety measures to be implemented were identified as follows: • • • Fitting of free swing devices to doors which are being propped open with wedges (four in total) Eliminate the need for oxygen Intumescent strip and smoke seals for all doors. At the last inspection we were told that action was being taken to resolve a problem of mould on one resident’s bedroom ceiling. Staff told us that the mould is cleaned away regularly but returns due to limited ventilation of the room. The mould was there at this inspection visit and could pose health risks to the person occupying that room. In the kitchen nearest to the office, the worktops and some cupboards were worn and/or damaged, exposing the chipboard. This is not hygienic and may pose risks to residents when they are preparing meals. Since the inspection visit, we have been told that work will start on the kitchen on 18 February 2008. All other areas of the home were clean and tidy. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent and qualified staff. There are thorough recruitment procedures to make sure that staff are suitable to work in care and to protect residents from possible harm and poor practice. EVIDENCE: All staff employed at the home have either achieved or are working towards a National Vocational Qualification (NVQ) at level 2 or above. The David Lewis Centre has a full induction programme for new members of staff and refresher training is offered each Monday and Tuesday at the organisation’s main site. They told us that all staff have received up to date mandatory training. No new staff have been employed at the home since the last inspection, so staff records were not inspected. The records have shown that the David Lewis Centre operates thorough recruitment processes, which include Criminal Record Bureau checks and these are managed from the Human Resources department at the main site. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is generally run well although problems in relation to fire safety processes and maintenance mean that the residents’ welfare is not sufficiently protected. EVIDENCE: The manager is registered with the Commission for Social Care Inspection and has relevant qualifications for the position she holds. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 19 Quality assurance is approached in a number of ways. Residents, relatives and other stakeholders are consulted on the quality of services and facilities provided and their views are welcomed and acted upon. A questionnaire is sent annually to all adult service users to find out what they think of the service provided. The centre is looking to develop a resident council with representatives from each house taking the views forward directly to the trustees of the organisation. A sample of records was inspected in relation to fire safety. The records showed that the fire alarms and emergency lighting were being tested regularly. However, recommendations made by the fire officer that intumescent seal and cold smoke seal strips should be fitted to all fire doors have not been acted upon in a timely manner to adequately safeguard the people living in the home. Northern Counties Housing Association owns the houses and they are responsible for the maintenance of the property. However, it is important that the residents who are supported by the David Lewis Centre and the staff employed by the David Lewis Centre are provided with a safe place to live and/or work. Some negotiations need to take place to ensure that work is carried out quickly, efficiently and is monitored to check that it is of a good standard. The accident record was inspected and showed that sixteen accidents had occurred since the last inspection. All accidents/incidents were recorded appropriately. David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 20 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 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 21 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 YA9 Timescale for action 15(2)(b) The care plans for people 28/02/08 living at the home, including risk assessments, must accurately reflect the person’s needs so that they receive the support they need. 23(4) Effective systems to ensure 28/02/08 that the requirements made by the fire officer are responded to promptly must be put into place to make sure that people who live in the home and staff are safe. This remains unmet from the last inspection 05/02/07 23 (2)(b) The damaged kitchen 28/02/08 worktops and cupboards must be repaired/replaced so that hygiene standards can be maintained and food can be prepared safely. 23(1)(a)(2)(b)(d) Action must be taken to 28/02/08 resolve the issue of mould on one resident’s bedroom ceiling so that his living space is free from health hazards. DS0000006673.V348627.R01.S.doc Version 5.2 Page 22 Regulation Requirement 2 YA24 3 YA24 4 YA30 David Lewis Centre - Bryce House RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection North West Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI David Lewis Centre - Bryce House DS0000006673.V348627.R01.S.doc Version 5.2 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. 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