Latest Inspection
This is the latest available inspection report for this service, carried out on 9th June 2009. it is an annual review prepared by CQC after examining previous reports and information from the provider. At the time of this report, CQC judged the service to be Good.
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.
For extracts, read the latest CQC inspection for Birdhurst Rise, 7.
Annual service review
Name of Service: Birdhurst Rise, 7 The quality rating for this care home is: The rating was made on: two star good service A quality rating is our assessment of how well a care home, agency or scheme is meeting the needs of the people who use it. We give a quality rating following a full review of the service. We call this review a ‘key’ inspection We do an annual service review when there has been no key inspection of the service in the last 12 months. It does not involve a visit to the service but is a summary of new information given to us, or collected by us, since the last key inspection or annual service review.
Has this annual service review changed our opinion of the service?
No You should read the last key inspection report for this service to get a full picture of how well outcomes for the people using the service are being met. The date by which we will do a key inspection: Name of inspector: Lee Willis Date of this annual service review: 0 8 0 6 2 0 0 9 Annual Service Review Page 1 of 8 Information about the service
Address of service: 7 Birdhurst Rise South Croydon Surrey CR2 7EG 02086812216 02086881723 Telephone number: Fax number: Email address: Provider web address:
www.caremanagementgroup.com Care Management Group Ltd Name of registered provider(s): Name of registered manager (if applicable) Ms Vivian I Okeke Conditions of registration: Category(ies) : learning disability Conditions of registration: Number of places (if applicable): Under 65 Over 65 8 0 The maximum number of service users who can be accommodated is: 8 The registered person may provide the following category of service only: Care Home Only (CRH - PC) to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning disability - Code LD Have there been any changes in the ownership, management or the Yes service’s registration details in the last 12 months? If yes, what have they been: Date of last key inspection: Date of last annual service review (if applicable): Brief description of the service Birdhurst Rise is a large detached property offering accommodation and personal support for up to eight generally `middle aged? adults with learning disabilities and behaviours that may challenge the service. We registered Vivian Okeke as the services manager in Janurary 2009, which she has
Annual Service Review Page 2 of 8 None been running since October 2007. The service has its own transport and is within ten minutes of walk of several main line bus routes and a local train station. South Croydon is also within easy walking distance that has a wide variety of community facilities and services, including local shops, cafes, restaurants, pubs, and banks. The property comprises of eight single occupancy bedrooms all with en-suite toilet and bathing/shower facilities. Communal areas are largely located on the ground floor and include a main lounge, separate dinning area, large open plan kitchen, a top floor visitor?s room, spacious entrance hall/lobby, laundry room, and two office spaces located on the ground floor and basement. There are sufficient numbers of communal bathroom and toilets located throughout the house. The large garden at the rear is well maintained. The home has developed clear information to help people who use the service and their representatives to understand what facilities and services are provided. Annual Service Review Page 3 of 8 Service update since the last key inspection or annual service review:
What did we do for this annual service review? We looked at all the information that we have received, and asked for, since this services last Key Inspection. This included: The services Annual Quality Assurance Assessment (AQAA) that was completed and returned to us by the registered manager. The AQAA is a self-assessment that focuses on how well outcomes are being met for the people who use the service. It also gave us some numerical information about the service. The comments made in the services first quarterly Newsletter, which was published in March 2009. Verbal feedback from a member of staff during a telephone conversation that took place on 8th June 2009. The results of the services previous key inspection report and what action has been taken to address all the outstanding Requirements and good practice recommendations made in it. All the significant incidents and accidents involving the people who use the service, which have occurred since the service was last inspected, and what action was taken by the home in response to them. These are called Regulation 37 notifications and the service is legally required to keep us informed without delay about the occurrence of such events and/or incidents. What has this told us about the service? CHOICE OF HOME: AQAA states the services Statement of purpose and Guide have been reviewed and updated, and a new quarterly newsletter introduced in the past year. The service has not received any new referrals or had any placements breakdown since its last Inspection. AQAA states all 7 people who currently live at the home have been given copies of their terms and conditions of occupancy. INDIVIDUAL CHOICES: AQAA states the service continues to have a range of tools that enables the people who live at Birdhurst Rise to express their views, which includes: the use of objects reference and communication boards/books with photos and pictures, easy read menus and complaints policy, monthly resident meetings, weekly 1 to 1 sessions with designated keyworkers, annual attendance at CMGs Service user Conference, care plan reviews at least bi-annually, and annual feedback from satisfaction questionnaires. The home also has a designated communications Champion who is responsible for liaising with other CMG homes and attending communication forums and courses. Manager told us that in the past 12 months care plans have been made far more person centred and that all staff who work there have received person centred care planning training. The manager was also able to demonstrate the service is aware of equality and diversity issues as she wrote in the AQAA - service users are supported with gender identity and self image by each being involved in the choice and purchase of clothing and hair styles. It also states they are planning to ensure all staff have more training Annual Service Review Page 4 of 8 to improve their equality and diversity awareness. Progress made to achieve this aim will be assessed at its next Key inspection. LIFESTYLE: AQAA states that as a result of listening to the people who use the service, choices and information about meals, community based activities, and holiday destinations have all been improved in the past 12 months. The services first quarterly bulletin contained a lot of photographs showing the people who use the service engaging in various domestic chores, including cake making and general cleaning. There were also pictures of a number of the people who use the service enjoying a night out bowling and on holiday. HEALTHCARE SUPPORT: The AQAA states staff do not currently handle or store any Controlled Drugs on behalf of the people who use the service. Individual health care action plans are in place and input is routinely sought from local psychiatrist team regarding medication reviews and mental ill health issues. Manager wrote we have a good relationship with the local GP and surgery. Progress made by the service to ensure anyone who is willing and able to take greater control of their medication is actively encouraged and supported to do so will be looked at in the services next Key inspection. COMPLAINTS & PROTECTION: No formal complaints have been made about this service in the past year. We have been notified about the occurrence of 3 significant incidents since this service was last inspected. We were notified without delay and it was clear from the information we received that staff on duty at the time had dealt with each incident in a very prompt and professional manner. The one service user who was injured as a result of being involved in one incident was treated by medical professionals, who had been promptly contacted by staff on duty at the time. This significant incident, which had clearly adversely affected the welfare of the injured service user, was referred to the local safeguarding team in accordance with agreed protocols. The incident was fully investigated by the Local Authority, but not upheld. Staff spoken with told us risk management strategies have been established to minimise the likelihood of a similar incident reoccurring in the future. AQAA states that the vast majority of the people who work at Birdhurst Rise have received training in recognising, preventing and reporting safeguarding issues. ENVIRONMENT: The new Bulletin states the home was recently painted and a new sensory room added. The Bulletin also told us the service plans to lay new carpets. This aim will be looked at during our next site visit to Birdhurst Rise. The manager confirmed in the AQAA that the alarming of an external door had been reviewed with all the relevant parties, including care managers. It was subsequently agreed to remove the patio door alarm on the grounds that it was restricting peoples freedom of movement unnecessarily. The outcome of the review regarding the bedroom door alarms will be assessed at the services next inspection. STAFFING: AQAA states staff have regular opportunities to share good practice and improve their own performance through regular staff meetings and 1 to 1 supervision sessions with senior staff.
Annual Service Review Page 5 of 8 Furthermore, the AQAA and Bulletin both told us that as recommended on its last report the vast majority of the current staff team had either achieved a National Vocational Qualification (NVQ) in (care Level 2 or above) or were enrolled on a suitable courses. The AQAA also stated that 100 percent of its current staff team had received training in the prevention and control of infection, and completed an induction. The manager confirmed in the AQAA that as recommended in the services last inspection report she will be mindful when recruiting of the ethnic imbalance that exists between the mainly white British service user group and the all black British staff team. Progress made to implement this good practice recommendation and redress the balance will be assessed at the services next inspection. It was positively noted that the gender mixes of both staff and services users is currently very well matched. AQAA states that almost a third of all the shifts worked in the first three months of 2009 were covered by temporary staff. The manager is clearly aware of all the issues referred to in this section of the report because she wrote the service could do better - if staff attended more specialist training (e.g. Mental health awareness); a full compliment of staff was recruited; and, they had greater involvement of the Local Authority in their training programme. Progress made to address the aforementioned matters will be assessed at the services next inspection. MANAGEMENT: As required in the homes last report the manager confirmed in the AQAA that she had now completed her Registered Managers Award (NVQ 4) and has also recently been registered (i.e. Jan 2009) by us a fit to run a residential care service for adults with learning disabilities. The AQAA also states the homes deputy manager is currently working towards his Registered Managers Award. AQAA states CMGs quality assurance arrangements ensure the service provides value for money because the organisation has established a quality and improvement team who carry out quarterly assessments of the home. The service also continues to be inspected on a monthly basis by either a manager or Regional Director representing CMG. The manager wrote she always addresses the issues identified in Regulation 26 reports produced as a result of the aforementioned inspections. Finally, according to the services AQAA its electrical circuits, portable electrical appliances, fire detection and fighting equipment, emergency lighting, call bell alarm system, gas appliances, and water heating system - have all been serviced or tested as recommended by the manufacturer or regularity body. Service also has written assessments on Control of Substances Hazardous to Health. What are we going to do as a result of this annual service review? We are not going to change our plan to carry out a key inspection of this service by 3rd July 2010 because we still rate 7, Birdhurst Rise as a two star good performing residential care home for adults with learning disabilities. Annual Service Review Page 6 of 8 However, we reserve the right to decide to inspect the service at any time if we have concerns about the quality of the service or the safety of the people who use it. Annual Service Review Page 7 of 8 Reader Information
Document Purpose: Author: Audience: Further copies from: Annual service review CQC General Public 0870 240 7535 (national contact centre) Our duty to regulate social care services is set out in the Care Standards Act 2000. The content of which can be found on our website. Helpline:
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