CARE HOME ADULTS 18-65
David Lewis Centre - Bryce House 3/4 Consort Close Bollington Macclesfield Cheshire SK10 5FB Lead Inspector
David Jones 5 6 7 22
th th th nd t and 26 th Unannounced Inspection February 2007 09:30 David Lewis Centre - Bryce House DS0000006673.V321765.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.V321765.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.V321765.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) 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.V321765.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 6th March 2006 Brief Description of the Service: Bryce House is a community-based 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 tehre 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 - Bryce House including fees and charges and copies of the most recent inspection report can be acquired by contacting the centres administrative staff or the registered manager on 01565 640000. David Lewis Centre - Bryce House DS0000006673.V321765.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 the David Lewis Centre, including this service, took place on 5, 6, 7, 21 and 26 February 2007. The visit was carried out by a group of 5 inspectors who looked at various aspects of this home and the way the David Lewis Centre runs. The visit was just one part of the inspection. Before the visit, the manager of the home was asked to complete a questionnaire to provide CSCI with up to date information about the home. CSCI questionnaires were sent out for residents 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 David Lewis Centre, including this home, was carried out; and inspectors 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:
People who are interested in moving into the home are given information, available in different formats, so they can make an informed choice about moving into the home. Residents benefit from a comprehensive assessment of their health and social care needs, personal preferences and aspirations. They are involved with the development of their individualised person centred plan, which confirms what arrangements are made to meet their needs and help them to achieve their goals and aspirations. One resident said that the move to Bryce House resulted in a huge improvement in his quality of life. He said that he had been able to identify with the Bollington community and had developed valued relationships and feels that he belongs there. Support workers help residents to explore and take advantage of opportunities for work, education, leisure and social inclusion in the local community and on site at the DLC. A programme of daily activities is in place for all of the residents and some are engaged in voluntary and paid work in the community. Residents participate in all ordinary domestic routines in the home including shopping, cleaning, menu planning and preparing meals. One resident spoke of the importance of healthy eating and said “he likes good food, appreciates choice and freedom to make decisions without restrictions other than safety”. Food was said to be good and a healthy option is offered at every mealtime. Being involved with all domestic routines helped this resident to develop their independent living skills.
David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 6 The organisation’s staff recruitment procedures and recently revised adult protection procedures ensure that residents are protected from harm. Support workers and managers benefit from a comprehensive staff training, development and support programme. One resident said, “The staff are caring and sensitive and skilled. They are knowledgeable about my needs”. This means that residents benefit from the care and support of competent and skilled staff team. Effective complaints and improving consultation procedures ensure that residents are listened to and their views and concerns acted upon and addressed. What has improved since the last inspection?
The manager and staff are able to show what changes they have made as a result of listening to residents. These include including improved educational, occupational and leisure activities and improved opportunities to become involved in staff recruitment and induction training. In addition managers, staff and residents have worked together to produce the “Charter of Resident Involvement.” This will ensure that residents are at the centre of decisionmaking and any future developments in the provision of facilities and services will reflect their changing needs and requirements. Progress is being made to the way in which residents’ medication is supplied and includes medication being available in their own home. The complaints procedure has been revised and re-established since the last inspection and a new adult protection policy and procedure has been introduced across the David Lewis Centre. This ensures there is a co-ordinated approach to protecting vulnerable adults. The David Lewis Centre has adopted the “Timian” model of practice for managing challenging behaviour presented by residents. This programme is accredited with the British Institute of Learning Disabilities B.I.L.D. Some staff across the centre have received training in de-escalation techniques within the “Timian” model of practice and this is to be made available to all staff at this home. Policies and procedures for handling residents’ money are currently under review. This will ensure the resident’s rights are respected and acknowledged and a robust system is in place to ensure the safety of money when handling transactions. The DLC is developing awareness about its strengths and areas for further development. Managers and staff are encouraged to explore opportunities for further development in the interests of providing a service that continues to meet customers’ needs by making the best use of available resources and improving efficiency and effectiveness.
David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 7 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.V321765.R01.S.doc Version 5.2 Page 8 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.V321765.R01.S.doc Version 5.2 Page 9 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): 1 and 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents and their representatives have the information they need to make an informed choice about the home. They have their needs assessed and a contract which tells them about the service they will receive. EVIDENCE: Residents have access to a statement of purpose and service users guide. These documents provide valuable information to assist new and existing residents and their families when making decisions about the home. Special versions of these documents can be made available to meet various communication needs presented by prospective residents. For example, one resident who is partially sighted had been provided with an audio version on a compact disc. One common care file was read in detail as part of a case tracking exercise. The resident had lived at the David Lewis Centre (DLC) for a number of years before moving into Bryce House when it opened in 1994. The common care file contained comprehensive information about the resident including a pen picture, listen to me document and a person centred plan. The resident confirmed that they had been involved with the development of their person centred plan and had in fact drafted it and typed it themselves. He said that he is entirely satisfied with his person centred plan and he finds it useful. He
David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 10 advised that the move to Bryce House resulted in a huge improvement in his quality of life. He said that “he has been able to identify with the Bollington community and had developed valued relationships and feels that he belongs there”. It was noted that another resident had recently returned to Bryce House from a short stay at the DLC Adult Assessment Unit (AAU). Support staff had been provided with a brief overview as to the outcome of this person’s stay on the AAU but this had not been confirmed in writing and the person centred plan had not been updated to reflect any resulting changes in care. It is essential that the assessment and person centred plan are updated as and when needs or circumstances change so care staff have the information they need to meet residents needs in a consistent and appropriate way. Terms and conditions documents are in place so residents have written confirmation of their rights and responsibilities regarding the provision of the service. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 11 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 and 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 in decisions about their lives, so they play an active role in planning the care and support they receive. EVIDENCE: The common care files read during the inspection visit and discussion with the resident confirmed that the person centred plan was devised with the resident’s full involvement. It was based on a comprehensive assessment and understanding of their needs, preferences and personal aspirations. It addressed risk assessment and the management of risk and clearly set out how the individual’s health and social care needs were to be met. The person centred plan and risk assessments were reviewed on a regular basis according to specified frequencies. Support staff were working in partnership with the resident to assist them to achieve their personal goals and aspirations. Three action points were listed in the person centred plan. These were: to remain healthy and safe, to become a more independent person and to live independently in a smaller house in the local community. It was clear
David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 12 that significant progress was being made in relation to the first two action points but there was no clear strategy as to how the resident would be helped to achieve their ultimate goal of living independently. The person centred planning process should be developed so residents are assisted to explore and evaluate all opportunities to realise their aspirations including those that may be presented by other personal care and support agencies. All such strategies should be recorded for the benefit of analysis and review and arrangements should be made to help the resident pursue their goals according to their chosen strategy. This will help residents deal with problems and blockages that may be preventing them from realising their life goals. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use services are able to make choices about their life style, and are supported to develop their life skills. Social, educational, cultural and recreational activities meet individual’s expectations. EVIDENCE: Support workers help residents to explore and take advantage of opportunities for work, education, leisure and social inclusion in the local community and on site at the DLC. A programme of daily activities is in place for all of the residents and some are engaged in voluntary and paid work in the community. One was interested in dry stone walling and was being supported to identify how this could be achieved. Another resident said he had become an integral member of the Bollington Methodist Church and was responsible for publishing the Church magazine. He said this was a source of great pleasure and pressure, especially when people always miss the deadline with material for
David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 14 inclusion. He also did voluntary work at an older persons’ home, socialising with them and playing the piano. Managers and support workers are able to demonstrate how they seek to help residents develop relationships as confirmed in their respective person centred plans. Residents enjoy a range of leisure activities including going to the local gym, restaurants, bowling alley and theme nights at the local pub. Residents participate in all ordinary domestic routines in the home including shopping, cleaning, menu planning and preparing meals. One resident spoke of the importance of healthy eating and said he likes good food, appreciates choice and freedom to make decisions without restrictions other than safety. Food was said to be good and a healthy option is offered at every mealtime. Being involved with all domestic routines helped this resident to develop their independent living skills. The resident spoke about the importance of risk assessment and said he knows that he will always need the support of care staff because of the severity of his epilepsy but his aim is to live as independently as possible in a home of his own. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The residents’ specialist health needs, including epilepsy and dietary requirements, are clearly recorded in person centred plans. Residents are closely monitored so potential health problems are promptly addressed by the appropriate healthcare services. The registered manager advised that all residents are registered with a community based GP although all receive specialist care for their epilepsy from the 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 health care needs. The registered manager is aiming to develop a working relationship with the local GP practice nurse in the interests of working in partnership. Health action plans are to be introduced for all residents. These will give a comprehensive
David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 16 overview of the individual’s health needs and will be valuable for health monitoring, as they will alert support workers to significant health changes. Residents are consulted and are actively involved in developing arrangements to meet their needs and personal preferences. Service users retain, administer and control their own medication where appropriate and receive occasional assistance with medication when necessary. Where medication has been prescribed on an as and when required basis the protocol for administration is detailed on the medication administration record. This facilitates immediate access to the information for care workers needing to take action in the event of a resident having a severe epileptic seizure. All relevant staff have received training in the administration, recording and safe keeping of medication. Since the last inspection in February 2006, managers of the David Lewis Centre have met with representatives of the Commission for Social Care Inspection, the Healthcare Commission, the Royal Pharmaceutical Society of Great Britain and the local Primary Care Trust to discuss the best way of supplying its residents with medicines, based on a community model. This is a better way than the hospital model used before. An action plan is in place and is being put into practice to ensure the necessary changes take place within an agreed timescale. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are protected from abuse and have access to an effective complaints procedure. EVIDENCE: The complaints procedure has been revised and re-established since the last inspection. Complaints records indicate that Bryce House had received three complaints since the last inspection. All had been investigated, acted upon and responded to within 28 days. Adult protection procedures have been revised since the last inspection and were much improved. They are robust and include a “Whistle Blowing Policy”. They reflect local multi-agency policies and procedures including the involvement of the Police and passing concerns on to the local authority and CSCI in accordance with the Public Interest Disclosure Act and the Department of Health Guidance No Secrets. 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 co-ordinated and monitored. The records kept by the social work department were checked and were seen to be thorough. Bryce House has responded appropriately to the only adult protection issue that had occurred since the last inspection. Information provided by the registered manager indicates that a significant number of staff had received training in adult protection and arrangements are in place to address further training needs.
David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 18 Information provided by senior management indicates that the DLC has adopted the “Timian” model of practice for managing challenging behaviour presented by residents. This programme is accredited with the British Institute of Learning Disabilities B.I.L.D. Some staff across the centre have received training in de-escalation techniques within the “Timian” model of practice and this is to be made available to all staff working at Bryce House. Assessment of each resident’s capacity to manage his or her own finances is central to the development of the person centred plan. Information provided by the manager indicates a detailed assessment of residents’ capacity to handle their finances will be carried out as and when appropriate. An independent advocate will be sought to ensure that the wishes and requirements of the resident will be ascertained and carried out. Policies and procedures for handling residents’ money are currently under review. This will ensure the resident’s rights are respected and acknowledged and a robust system is in place to ensure the safety of money when handling transactions. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 19 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, 25, 28, and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although the home was clean and comfortable for the people who live there, delays in responding to the fire officer’s recommendations may leave them and staff at risk. EVIDENCE: Residents live in comfortable and well-maintained environment, which is well equipped and encourages independence. The premises are purpose built and are suitable for their stated purpose. The landlord of Bryce House is Northern Counties Housing Association and the individual service users have license agreements. The Housing Association is responsible for the maintenance of the building. Records are available in the home that identify any remedial action reported and dates of completion of remedial work. The premises are indiscernible from neighbouring domestic properties and are in keeping with the local community other than a sign that had been put up outside by the housing association. The sign has been defaced with spray
David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 20 paint. It detracts from the otherwise domestic appearance of the premises. Representations should be made to the housing association for its removal. Bedroom doors had not been upgraded to meet the recommendations of the fire officer as detailed in inspection reports dated 4th April 2005 and 6th 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 home was warm and clean and aesthetically pleasing. The premises were clean with no evidence of any offensive odours. The lighting was sufficient to meet the needs of the residents and furnishings, fixtures and adaptations were of a good quality and domestic in nature. Computers, music systems, TVs and DVD players were seen in communal areas for resident’s use and enjoyment. Three residents’ bedrooms were seen during the inspection visit. All contained personal possessions. One resident said, ‘I like spending time in my room’ and ‘I like my ornaments and listening to country and western music’. Action was being taken to resolve a problem of mould on a bedroom ceiling. The housing association had fitted two large extractor fans in the corridor ceiling. The ceiling waits repainting and the housing association has agreed to do this as soon as possible. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 21 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 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a site visit to the service. Residents are supported by competent and qualified staff and are protected by thorough staff recruitment procedures. EVIDENCE: Residents are protected by the organisation’s recruitment procedures. A number of staff recruitment records chosen at random confirmed that the David Lewis Centre operates thorough recruitment procedures that meet the requirements of the regulations and incorporate equal opportunities and anti discriminatory practice. Staff are employed in accordance with the code of conduct set by the General Social Care Council and are provided with a copy of the code. The staff files that were inspected contained all the necessary information to show that thorough checks were made before staff started working with residents at the centre. A competent and qualified team of staff supports and provides personal care for residents in accordance with their needs. One resident said, “the staff are caring and sensitive and skilled. They are knowledgeable about my needs”. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 22 Support workers and managers benefit from a comprehensive staff training and development programme. The induction course for new staff has been revised to incorporate ‘Skills for Care’ criteria and training standards and information provided by the registered manager confirmed that 75 of the support staff team have an NVQ in care at level 3. Training is delivered via the centre’s training centre offering training to NVQ 3 and 4, mandatory training and other specialist topics. All staff members have had the benefit of an appraisal. Information provided by human resource department regarding staff training did not reflect the current situation. Training records held by the registered manager indicated that the vast majority of staff had completed their mandatory training in the last 12 months period with the exception of two who were due to complete medication training in the following week. Records confirm that staff receive supervision on a consistent and regular basis. This ensures that residents’ benefit from a well-supported staff team. However staff working alone at nighttime are not supported by a rostered on call system. The registered manager and other staff members make themselves available for support on an informal basis but there are no guarantees that they will be able to respond to a call for assistance. There are safety issues in relation to staff working alone. Should an emergency arise during the night the staffing situation could prove problematic. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 23 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 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a site visit to the service. Although the home is generally run well, problems in relation to fire safety processes 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. There are clear lines of accountability within the DLC from support workers up through the chain of command to the chief executive. The registered manager at Bryce House is supported and line managed by the registered manager of Unit One. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 24 Information provided by and discussion with the registered manager and other staff indicates that the DLC is developing awareness of its strengths and areas for further development. Managers and staff were encouraged to explore opportunities for further development in the interests of providing a service that continues to meet the needs of the people who use the Centre by making the best use of available resources. 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 has been sent to all adult service users to ascertain their views of the service provided. The results were collated and feedback was given to all residents. The registered manager is able to demonstrate what changes have been made as a result of listening to residents including improved educational, occupational and leisure activities and improved opportunities to become involved in staff recruitment and induction training. The registered manager carries out a number of quality checks on an on going basis and arrangements were in place to audit person centred plans. Other developments for improving opportunities for residents to participate in the running of their homes include a Charter of Resident Involvement, which is available in user-friendly language. Residents and their representatives are invited to attend an annual review, which focuses on the quality of service. Residents meetings take place to give them the opportunity to participate in the day to day running of the home and enable them to select and plan social activities. The David Lewis Centre’s health and safety officer has responsibility for health and safety training for staff on induction, for updates on training and for risk assessments relating to the houses. The records he held on fire safety training, including phased evacuation, were incomplete and did not correspond with the records held in the individual houses. There was insufficient evidence, therefore, to confirm that all staff are receiving their mandatory fire safety training. There are lengthy delays in referring recommendations and requirements made by the fire officer to the David Lewis Centre’s maintenance department for action. Records are retained in the maintenance department of the completed work but no process is in place to ensure that the work is monitored by the health and safety officer. Fire risk assessments produced by the Centre were completed a number of years ago and reviewed following the fire officer’s visit. The reviews have been written as audits of the premises and should now be supported by a fire risk assessment in line with current guidance. The health and safety officer has an
David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 25 audit programme for the houses to cover fire safety tests, COSHH etc that will take place every 4 – 6 months. However, these haven’t started yet – the first one will take place within the next few months. Accident records are completed in the houses and copies are sent to the health and safety officer to monitor. He collates the information and reports each month to the Chief Executive of the David Lewis Centre. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 26 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 3 2 2 3 X 4 X 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 2 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 X 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 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 2 X 3 X 3 X X 2 X David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14 (2) (a) and (b) Requirement Assessments of residents’ needs must be kept under review and revised as and when their circumstances and needs change. The changes to provide medication as outlined in the David Lewis Centre’s action plan must be implemented without undue delay. Effective systems to ensure that the requirements made by the fire officer are responded to promptly must be put into place. Timescale for action 30/04/07 2 YA20 13(2) 31/12/07 3 YA24 23(4) 31/05/07 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 The person centred planning process should be developed so residents are assisted to explore and evaluate all opportunities to realise their aspirations including those that may be presented by other personal care and support agencies. All such strategies should be recorded for the
DS0000006673.V321765.R01.S.doc Version 5.2 Page 28 David Lewis Centre - Bryce House 2 3 YA33 YA42 benefit of analysis and review and arrangements should be made to help the resident pursue their goals according to their chosen strategy. This will help residents deal with problems and blockages that may be preventing them from realising their life goals. The night time on call rota should be formalised, to ensure that lone staff have access to appropriate levels of support when required. The fire audits should be supported by revised fire risk assessments in line with current guidance from the fire officer. David Lewis Centre - Bryce House DS0000006673.V321765.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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.V321765.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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!
