Inspection on 02/06/05 for Northernhay

This inspection was carried out on 2nd June 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

Northernhay 09/01/07

Northernhay 01/02/06

Northernhay 06/01/05

Northernhay 05/07/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Northernhay 1 Bickley Road Bromley Kent BR1 2ND Lead Inspector Lorraine Pumford Unannounced 2 June 2005 2.30pm nd 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. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Northernhay Address 11 Bickley Road, Bromley, Kent, BR1 2ND 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) 020 8295 3757 020 8467 7211 Bromley Autistic Trust Hayley Gilham Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 06/01/05 Brief Description of the Service: ‘Northernhay’ is a large, detached Victorian house, which provides accommodation and care for six service users with autism. Hyde Housing Association owns the building and the service provider is Bromley Autistic Trust, which also employs the staff. The house is spacious and has private and communal facilities to meet the service users’ needs. It has a large, enclosed back garden and some off-street parking at the front. ‘Northernhay’ is situated on a main road and bus route leading to Bromley town centre. For people with full mobility, it is within reasonable walking distance of a rail station. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken by one inspector who was in the home for approximately 3.5 hours. During that time some records were examined, parts of the premises inspected and a number of service users were spoken with. The manager and deputy manager were the only staff on duty. They have worked for the Bromley Autistic Trust for a number of years and they also provided information. What the service does well: What has improved since the last inspection? The manager has arranged for medication to be appropriately stored. No errors were found in relation to the recording and administration of medication to service users. Action has been taken to eradicate a damp patch in a service user’s bedroom and the room has also been redecorated. Care staff have been provided with a copy of the General Social Care Council’s standards and good practice. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 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. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 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 Northernhay G51-G01 s6958 Northernhay UI v227092 020605 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) 1,2,3,4,5 Service users and their relatives are provided with documentation regarding the fee, facilities and services provided, enabling them to make an informed decision regarding the home’s ability to fulfil their needs. Although there have been no new admissions for some time the home has written procedures in place to assess the needs of potential service users. EVIDENCE: The manager stated that the current service user group has remained stable for a number of years. However in the event of a vacancy occurring, any prospective new service user would be given the opportunity to visit the home on a number of occasions to enable them to meet with peers, care staff and to familiarise themselves with their room and the house in general. The manager stated that the trust has a set pre-assessment format that would be completed prior to the admission of any new service user to the home. The manager stated that there was a contract between service users and the Bromley Autistic Trust, regarding the care and services to be provided. However a copy of this was not available on this occasion. Letters on service users’ files indicated that the trust provides service users with a letter annually regarding the fees payable and any relevant parties’ contribution to the cost of the placement. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 9 Copies of tenancy agreements provided by Hyde Housing in relation to the occupancy of the building were seen. Discussion took place in relation to the Statement of Purpose and the Service User Guide; the manager has additionally prepared this information on a video that is a user-friendly format for the service users accommodated. This includes information about fees, facilities and activities as well as the complaints procedure. The video of the Statement of Purpose and the Service User Guide did indicate the home’s responsibility in relation to the purchasing of bed linen, however, not in relation to the purchasing of towels or redecoration of bedrooms. The manager stated that the home is not responsible for the purchasing of towels and this information should be placed in the Service Users Guide. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 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) 6,7,9,10 There are detailed records regarding service users’ assessed needs with clear aims and objectives and guidance for service users and staff regarding action to be taken to meet these. Service users can be assured that all information regarding then will be treated as confidential. EVIDENCE: Information regarding the service users’ care, health, social activities and any other relevant information is formulated into two documents: the care plan which is primarily staff orientated and the person centred plan (PCP) which is more service user orientated. One of the residents was keen to show the inspector this document in relation to himself; information that was recorded was detailed and conveyed in a format suitable for the service user i.e. by the use of photographs and easy to follow diagrams. Staff had accessed relevant health professionals to insure the most up-to-date treatment was available to a service user with a specific medical condition. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 11 There was evidence that a service user’s PCP had been updated regularly. However the manager stated the main care plan was overdue a review. The manager stated that service users’ care managers were always invited, however, seldom attended formal reviews. Care staff ensure that regular meetings take place with service users and their representatives to review service users’ PCPs to ascertain if the aims and objectives are being achieved or need to be amended. Evidence was seen that risk assessments are completed in relation to service users using public transport, going on holidays etc. The manager stated that there were occasions when only one member of staff would be in the house with a service user. Discussion took place around the need to complete a risk assessment in relation to this practice to ensure that a member of staff was not left alone with a service user whose behaviour may be potentially aggressive or unpredictable. Further that any service user left alone with one member of staff must know the action to take in the event of an emergency with the member of staff being unable to raise the alarm. There was evidence to indicate that staff respect service users confidentially. Staff asked permission from service users to access records pertaining to them before providing the documents for inspection. Information regarding service users is stored in locked filing cabinets when not in use. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 12 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) 12,13,15,17 Social activities and meals are both well managed, creative and provide daily variation and interest for service users. EVIDENCE: Service users attend various day centres and workshops within the local community on a daily basis. Staff assistant service users to access local amenities such as public houses for meals out or a game of pool. Service users’ hobbies and interests are encouraged i.e. one service user attends a local train enthusiasts club. Other service users attend Gateway, which is an evening social group. An art therapist holds regular sessions in the home for service users. The home has its own transport for service users; in addition some staff have appropriate insurance to enable them to transport service users in their private cars. The manager stated that an agreement has been made between themselves and a local taxi company which understands the particular difficulties the service users may experience. Individual risk assessments have been completed in relation to service users using this form of transport. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 13 The manager stated that “befrienders” had provided support to service users on a one-to-one basis in the past, however contact had recently dwindled. The manager stated that all the service users are given the opportunity of having an annual holiday, generally a maximum of two service users are accompanied by two members of staff. Plans are currently underway to arrange a holiday in the Netherlands. The video Service User Guide states that relatives and visitors are welcome any time. The home has a room available for private conversation, which is appropriately furnished for the purpose. There is also a telephone situated in this room to enable service users to make calls in private. Copies of the home’s menus were examined. These indicated that service users are provided with a varied nutritious diet. The staff stated that the menus were discussed at house meetings, the menu indicated that service users’ individual likes and dislikes were taken into account. At present a record is being kept in relation to the evening meal. This needs to be developed to include details of food provided at lunchtime to service users who have remained at home during the day. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 14 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) 20,21 Considerable progress had been made regarding the practice and protocols for storing and recording medication. Information regarding service users wishes in respect of action to be taken following death are included in the individual care plans. EVIDENCE: A number of issues had been raised during the previous inspection in relation to the storing, recording and administration of medication. All of these issues had been addressed. At present staff are responsible for obtaining medication for the service user who lives in the flat above the home, they give the dossette to the service user each week to administer the medication herself. Self-medicating had been written on the medication record, staff stated the service user has declined to sign the MAR sheet to acknowledge receipt of the medication. In this instance the process should be monitored and signed by staff. The manager stated that where possible service users wishes’ in respect of action to be taken following death had been included in service users care plans. When this had not been possible due to service users limited understanding of the matter, information had been sought from relatives etc. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 15 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) 22 Service users and their representatives are provided with information regarding the Bromley Autistic Trust Complaints procedure. EVIDENCE: The Bromley Autistic Trust complaints procedure is available in a written format and on the video version of the Home’s Statement of Purpose. To date the CSCI have not received any complaints regarding the care or service provided at Northernhay. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 16 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) 24,25,26,27,30 Service users live in a homely, comfortable environment with adequate personal and communal space. However the home would benefit from an ongoing programme of general maintenance and redecoration. EVIDENCE: The lounge and dining room are appropriately furnished and provide a comfortable and homely environment. Patio doors from the lounge lead out into a large garden, accessible for the service users. Northernhay provides all service users with single bedrooms; there are an appropriate number of bathrooms and toilets with the choice of bath or shower. Radiators are provided with safety covers. The manager stated that safety valves are fitted to the bath to regulate the temperature of water; in addition staff use a thermometer to check and record the water temperature when preparing baths for service users. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 17 Service users’ bedrooms are individually personalised and where possible reflect their hobbies and interests. A service user stated he had everything in his room he required. A service user who had requested a key to his bedroom had been provided with one. At the time of the last inspection a requirement had been made to repair a damp patch on the wall in a service user’s bedroom. This matter has now been addressed and the bedroom has been redecorated. The manager stated and records indicated that there is a limited budget for redecoration. In these circumstances, with limited finances, essential works take precedence over general updating and maintenance of the property, and in one instance this has led to the service user’s relatives offering to redecorate a bedroom as it has not been redecorated since the home opened approximately eleven years ago. The manager needs to ensure a regular audit of the premises is undertaken to identify areas of the building or fixtures and furnishings which require improvement or replacement. Where possible, action should be taken to address the matter or, for larger issues with budgetary implications, a plan of action with timescales needs to be developed. At present the following points need to be addressed. 1) The flooring in the shower room still requires remedial attention to ensure that it is safe and waterproof and can be efficiently cleaned. 2) A number of bedroom windows were dirty and the view through the glass considerably impaired. 3) One service user’s bedside light had a torn and stained shade. 4) The ground floor toilet is in need of redecoration, the walls are scuffed and woodwork and skirting boards are chipped, the lino is also worn and stained. This needs to be addressed to enable staff to effectively clean the room. The laundry was clean and well organised; the manager stated that the equipment meets the needs of the current service user group. The kitchen was clean and the manager stated that following an inspection by the Environmental Health Department the home had been awarded a clean food award.” Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 18 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) 32,34, All staff are appropriately trained and qualified to meet the assessed needs of the service users accommodated. The home would benefit from the manager taking part in the recruitment procedure allowing her to match the skills of applicants to the existing staff group. EVIDENCE: A number of care staff have successfully completed NVQ qualifications in care. All care staff have been provided with a copy of the General Social Care Council’s standards and good practice. The manager stated that due to members of staff being on leave, the Trust’s bank staff was covering additional hours. Recruitment procedures were discussed. The manager stated that the Bromley Autistic Trust generally runs a recruitment drive to recruit staff for both the residential home or day centre that it currently operates. This could lead to staff being recruited to work in a home without the registered manager being involved in the process. This recruitment process is unsatisfactory as the home’s manager should be involved in the recruitment process of staff enabling them to match the skills of applicants to the existing staff group. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 19 The manager stated that Bromley Autistic Trust operates an equal opportunities recruitment policy; the use of scenarios in the process enables staff interviewing to assess how potential staff cope with day-to-day incidents that may occur in service uses lives. The manager stated that all staff working in the home have received appropriate CRB checks. The manager stated that there may be instances of staff being employed who have not had experience of working with service users with Autism, however the trust provides comprehensive training in relation to this condition, which all new staff would receive prior to the commencing care duties. There is an induction programme that should be signed by the new member of staff and the person supervising to indicate that the policy or procedure has been covered and the member of staff fully understands the matter. In addition to the care of the six service users, care staff provide an additional 15 hours of support (funded by the government initiative supporting people scheme) to the person living in the flat above the home. In addition to care and supervision of service users, staff are responsible for undertaking cooking, laundry and all administration tasks. The manager stated some staff have also undertake responsibility for some redecoration of rooms and maintenance of the large garden. The amount of time that staff spend undertaking non-care duties should be taken into account when calculating the number of care hours required for the effective operation of the home. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 20 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, The manager is suitable qualified and competent to manage the home on a day-to-day basis. EVIDENCE: Since the last inspection the manager has completed the Registered Managers Award and has commenced the NVQ assessors course. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 21 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 2 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 2 Standard No 31 32 33 34 35 36 Score x 3 x 2 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Northernhay Score x x 3 3 Standard No 37 38 39 40 41 42 43 Score 3 x x x x x x G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 22 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 1 Regulation Requirement Timescale for action 30.07.05 2. 30 17(2)Sch4 Keep a record of the homes .8. charges including any extra amount payable by service users. 23(2) Ensure that all parts of the home 30.9.05 are well maintained and staff can maintain good standards of hygiene. 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. Refer to Standard 42 17 Good Practice Recommendations Risk assessments are undertaken in relation to staff working alone in the house with a service user. The record of food provided to service users includes lunches when provided by staff at home. Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 23 Commission for Social Care Inspection River House 1 Maidstone Road Sidcup DA14 5RH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Northernhay G51-G01 s6958 Northernhay UI v227092 020605 Stage 4.doc Version 1.30 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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