Care Home: Byrnhill Grove

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What the care home does well The home is extremely well maintained, bright and comfortably furnished. The 16 en-suite bedrooms are large and provided both the opportunity to create a sleeping and lounge area. The Records maintained by the staff are clear, well presented documents that contained detailed information about the residents and are regularly reviewed and updated. The service users accessibility to appropriate health and social care support is good, with records documenting when people are in contact with professional agencies and a comment made via the surveys: `Very good support with an excellent Doctor`, summing up the feedback provided by the residents. Staff training and development opportunities are reasonably good, as confirmed by the staff during conversations. The residents are afforded the opportunity to comment on the service provided both during the residents meetings, which are regular occurrences at the home and surveys, records indicating that the manager has recently completed a survey. What has improved since the last inspection? New profiling beds have been purchased and provided to the service users. Changes have been made to the way staff are deployed, the manager has increased the night staffing arrangements to two wakeful night staff. She has also introduced a team working model and a keyworker system into the home, the staff divided into three distinct teams and allocated specific residents within each team. Record indicate that the manager is in the process of updating the home`s menus, with a view to improving the range and choice of meals provided to the residents`. What the care home could do better: The residents` lack stimulation and entertainment, with no planned activities programme in place, and records evidencing that people are often attending or taking part in three to four events a month. CARE HOMES FOR OLDER PEOPLE Byrnhill Grove Park Avenue Ventnor Isle Of Wight PO38 1LR Lead Inspector Mark Sims Unannounced Inspection 28th April 2008 11:15 X10015.doc Version 1.40 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 Byrnhill Grove DS0000066063.V361241.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 Older People. 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. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Byrnhill Grove Address Park Avenue Ventnor Isle Of Wight PO38 1LR 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) 01983 852495 01983 539040 South Wight Housing Association Ltd Mrs Christine Elizabeth Osborn Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th April 2007 Brief Description of the Service: Byrnhill Grove residential care home provides care and accommodation for up to 16 older people. Mrs Christine Osborn manages the home on behalf of the providers South Wight Housing Association Ltd. The home is a purpose built property opened in 1987 and located in Park Avenue Ventnor, close to the park and within approximately a half mile of the town with its shops and amenities. The home is integral to sheltered housing accommodation and has shared communal facilities. Residents’ rooms are for single occupancy and have en-suite facilities. They are located on the ground floor and accessible to all the residents. Access to some of the supported housing flats is through the residential home. Communal areas are located at ground level and comprise a large lounge with vaulted ceiling, a smaller quiet lounge, a garden lounge and a dining room. Residents have access to communal bathing and additional toilet facilities. The home provides 24 hours staffing. Weekly fees are £434.96. The manager states that a copy of the home’s statement of purpose and brochure are provided to all residents or their representatives where applicable. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. This inspection was, a ‘Key Inspection’, which is part of the regulatory programme that measures services against core National Minimum Standards. The fieldwork visit to the site of the agency was conducted over four hours, where in addition to any paperwork that required reviewing we (the Commission for Social Care Inspection) met service users, staff and management. The inspection process involved pre fieldwork activity, gathering information from a variety of sources, surveys, the Commission’s database and the Annual Quality Assurance Assessment information provided by the service provider/manager. The response to the Commissions surveys was poor, with two service user surveys returned prior to the report being written. What the service does well: The home is extremely well maintained, bright and comfortably furnished. The 16 en-suite bedrooms are large and provided both the opportunity to create a sleeping and lounge area. The Records maintained by the staff are clear, well presented documents that contained detailed information about the residents and are regularly reviewed and updated. The service users accessibility to appropriate health and social care support is good, with records documenting when people are in contact with professional agencies and a comment made via the surveys: ‘Very good support with an excellent Doctor’, summing up the feedback provided by the residents. Staff training and development opportunities are reasonably good, as confirmed by the staff during conversations. The residents are afforded the opportunity to comment on the service provided both during the residents meetings, which are regular occurrences at the home and surveys, records indicating that the manager has recently completed a survey. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 3 & 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who may use the service and their representatives have the information needed to choose a home that will meet their needs. EVIDENCE: The service tells us, via their AQAA that: ‘when a prospective service user or their family, enquire about our service, I send them a brochure and copy of our Statement of Purpose, which includes the service user guide. The initial enquiry is usually an informal discussion when they are invited to ask as many questions as they wish. This conversation also gives us an opportunity to ask about the care needs of the prospective service user. A full needs assessment is undertaken by either myself or a senior carer; who is competent to do so, prior to admission. The assessment looks at the prospective new service user, in a holistic manner. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 9 The prospective service user and their loved ones, are invited to spend some time with us, either for coffee, tea or lunch, or even for the prospective service user to come in day-care, or for a short respite stay. When they visit, they are shown the available room and have a chat with the staff and other service users. This gives them the opportunity to have a good and look around, in order for them to make an informed decision. We make sure that they are not pressured into making a decision, but give them as much time as they need. We ensure, any prospective service user and/or their loved ones are made welcome, by offering a friendly and open attitude. We always put their individual needs as a priority by recognising the diversity each individual brings. We aim to ensure that we are able to offer and ultimately provide the care needs for promoting their wellbeing’. During the fieldwork visit a person, newly admitted to the home was spoken with, the person confirming that they had prior knowledge of the home, as they had stayed at Byrnhill Grove before and that when the time came to look for a place to convalesce this was the only place they consider. The person also felt they had been provided with sufficient information about the service, before agreeing to stay and had a copy of the ‘statement of purpose’ / ‘service users guide’ provided. During the tour of the premise each resident visited in their bedroom was noted to have a copy of the ‘statement of purpose’ / ‘service users guide’ document available in their room. Information taken from the residents surveys indicate that one of the two people received a contract on entering the home and that both parties received enough pre-admission information about the home, so they could decide if it was the right place for them. The home does not provide an intermediate care service and so this standard is not applicable. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7, 8, 9 & 10. 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: Four ‘service user plans’, were reviewed during the fieldwork visit. The service uses a ‘kardex’ system, which is a care documentation package purchased from an independent management company. The ‘kardex’ system is a structured programme, which provides the service with all of the basic tools and documents required to produce a ‘service user plan’, which during the visit included: admission details, care plans, personal care records, elimination records, social activities records, medication sheet, health and social care professional visits, moving and handling assessments, Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 11 nutritional assessments, risk assessments, dependency profiles and daily records. All of the records seen, whilst reviewing the ‘service user plans’, were well maintained and contained evidence of regular monthly reviews having taken place. The personal care, elimination and social activities records are all tick box documents, which the staff complete to confirm the completion of a task or the taking place of an event/activity, etc. The remaining documents all require a written entry and provide a reasonably detailed account of the persons’ care needs’, routines and involvement with health and social care professionals. During the review of the ‘service user plans’ the risk assessments were discussed with the senior carer on duty, as the plans could be further developed to ensure that actual risks to the clients are identified and then plans to manage these risks produced, based on how likely they are to occur. The senior carer is to discuss with the manager and other staff the development of the services risk assessment process. The service tells us via their AQAA that: ‘we provide a person centred, holistic approach to the delivery of care for our service users. The privacy and dignity of our service users is promoted in everything we do. Within the care plans, we review and monitor the nutritional requirements and weight of each service user regularly’, as reflected above the statement made via the AQAA is reasonably accurate’. The indication from the residents’ surveys is that people generally receive the care and support they require, with one person ticking ‘always’ and the other ‘usually’ in reply to the question: ‘do you receive the care and support you need’. People spoken with during the visit also provided evidence and/or testimony to the support provided by the staff, one person discussing how the staff encourage and support their mobilising, which is part of the rehabilitation they are making post an accident. People also discussed the support they receive when accessing health and social care services, both residents’ taking the opportunity to reflect, via the survey, that: ‘they receive the medical support they need’, one person adding: ‘very good support with an excellent doctor’. The ‘service user plans’, as referred to above, also contain documented evidence of people’s involvement with health and social care professionals, Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 12 these records including running records and correspondence between health care providers and the resident. The service tells us, via their AQAA that: ‘each service user has the choice to keep their original General Practitioner (G.P). and/or outside healthcare providers/agencies, or if they are out of area they can choose, who they prefer. We arrange transport and escort for each service user when attending hospital appointments, etc. If a service user becomes unwell, we ensure they receive the fullest attention, by calling for medical intervention. We work closely with the district nurses, who advise us on any health related issues, such as potential pressure sores, wound care and incontinence, etc. Risk assessments are carried out for those who may be vulnerable to pressure sores and the appropriate treatment/equipment is provided if necessary. Our staff are sensitive to the needs of the dying and their families and have experience of caring for the terminally ill, with dignity and respect’. Evidence obtained, whilst reviewing the ‘service users plans’, support the claim that people are escorted and/or supported when attending hospital or clinic appointments. An entry in a residents’ running record, backed up by an entry in the accident logs, documents how, following repeated complaints by the resident, about their health, contact was made with NHS Direct and a decision taken to admit the resident to A&E. The record describes how the manager was contacted regarding this issue and that they returned to the home to provide the escort for the resident. Observations made during the fieldwork visit, established that all several service users have been provided with profiling beds, that ease access during the delivery of personal care and assist in making people’s positions comfortable if they are on bed rest, etc. The care staff were also noticed to have access to a range of moving and handling equipment, including free moving hoists, static bath hoists and wheelchairs. Other equipment provided by the service to promote and ease the delivery of care included a medications cabinet, which enables the staff to safely transport people’s medicines around the home during medication administration. The storage of the service users medication was reviewed during the fieldwork visit and found to be safe and secure, whilst the records appertaining to the handling and administration of the residents’ medicines generally accurate and Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 13 up to date, although the manager should ensure that the sample signatures/initials for the people involved in administering medicines is current. The service tells us, via their AQAA that: ‘each service user is given the opportunity to be responsible for self-medication, following a risk assessment. However, the majority of our service users choose to have their medication administered by trained and competent staff. A comprehensive medication policy is in place, which gives clear guidelines for staff and service users to inform their practice’. A review of the medication procedure used by the service was undertaken during the visit and was found to be a clear and concise document, however, guidance has been produced by the ‘Royal Pharmaceutical Society’ on the safe management of medicines in social care settings, it was advised that a copy of this document be obtained, as a supplement to the services own policy and procedure. All accommodation, provided at ‘Byrnhill Grove’ is single occupancy with an ensuite facility. Residents’ bedrooms and all communal facilities are fitted with locks that are appropriate and/or suitable for the residents’ given their varying physical ailments. The service has three lounges, the main ‘atrium’ lounge and two smaller lounges that can be used by the residents’ to entertain family and/or professional visitors. Records, relating to the residents’ and their particular care needs are held within a central office, secured within a filing cabinet, which is accessible to the staff and authorised personnel only. The service tells us via their AQAA that staff have access to policies and procedures, meant to promote privacy: ‘Access to files by staff/users’ – last reviewed in the October of 2007, ‘Confidentiality and disclosure of information’ – last reviewed in the April of 2007 and ‘Values of privacy, dignity, choice, fulfilment, rights and independence’ – last reviewed in the August of 2007. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 14 & 15. Quality in this outcome area is adequate. 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 supported to develop their life skills. Social, educational, cultural and recreational activities could be improved to better meet individual’s expectations. EVIDENCE: The ‘service users plans’, reviewed during the fieldwork visit, contain a section that documents and/or records the activities and entertainments attended by the residents’ at Byrnhill Grove. The evidence provided by these records indicate, that the residents’ are being provided with very little internal stimulation and/or opportunities to enjoy or participate in events organised by the home. One persons’ file establishing that in March 2008 they attended seven activities, including three visits to the hairdresser, two occasions when they entertained visitors, one bingo session and one session of movement to music. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 15 In April 2008 the person enjoyed another seven activities, three visits by the hairdresser, two bingo sessions, one visit by a lay preacher for communion and one session of movement to music. Another residents’ records show that they have attended no activities since the 14th February 2008, which was a visit by the chiropodist and only one activity for the month before, January 2008, which was a hairdressing visit. A third persons file indicates that in March 2008 they attended six activities, five of which were visits by relatives/friends and one and outing with a relative. In the April 2008 there was one entry, which indicate that they had a visitor. Information taken from the residents surveys indicate that people feel the service provides unsatisfactory access to entertainments with both respondents ticking ‘sometimes’ in reply to the question ‘Are there activities arranged by the home that you can take part in’, one person adding ‘There are very few activities or outings arranged that the residents can take part in’. During the fieldwork visit the opportunity to speak with residents and relatives was taken, one person stating that activities and entertainments are poorly provided and that staff make little or no effort to stimulate the service users. However, the staff, when asked about activities stated that over the years they had tried various activities and entertainment programmes and people were generally not interested and failed to attend or take up the opportunities arranged. During the fieldwork visit no planned activities or spontaneous engagement with the residents’ were observed, which support the views of the residents’ and their visitors that stimulation for people is unsatisfactory. The service tells us, via their AQAA that: ‘we welcome visitors to our home, at any time suitable to our service users, who have the opportunity to receive them either into their rooms or our communal areas. We encourage relatives and friends to join us to celebrate special events such as service users birthday parties. We also offer the facility for relatives and friends to dine with service users, for a small cost this is very popular especially on a Sunday. We also have the facility of a guest flat for family and friends, who travel from the mainland to use at a minimal cost. During the fieldwork visit a relative staying in the flat, mentioned above, was spoken to, she stated that she visits regularly throughout the year and that the flat is a useful resource, although the amenities are basic and there is an ongoing problem with the shower, which she has mentioned to the manager. Other visitors were seen and spoken with during the fieldwork visit and all seemed happy with the services arrangements for visiting, which are contained Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 16 and/or detailed within the ‘service users guide’ and ‘statement of purpose’ documents. Copies of these documents were seen on display in the corridor leading to the home and in the rooms of the service users visited. The ‘service user plans’, as mentioned above, also provided evidence of people entertaining visitors to the home, both social and professional, as did the visitors’ book, which people are asked to sign on arriving and departing the home. Also mentioned earlier within the report, is the provision of two small lounge’s, which can be used to entertain visitors and the fact that all accommodation is single occupancy, which provides additional privacy during visits, the relatives spoken with during the fieldwork visit were all with a resident in their room when interviewed by us (the Commission). Whilst visiting people in their bedrooms we were able to establish that each room had been personalised by the occupant, with people using furniture, pictures, ornaments and photographs to create an individual feeling within their room. In discussion with the senior care on duty it was stated that all bedrooms are blank canvasses when people visit, with a view to moving into the home and that they are encouraged to bring with them any personal items they wish. If the person does not wish to provide or use their own furniture or fittings, etc then the service provides the basic necessities, i.e. bed, chairs, table, television, etc. The people residing at the home are also supported by the service to retain control over those aspects of their lives that they can, i.e choice of rising and retiring time, one persons’ plan documenting how they like to watch television until late. Choice of menu, with minutes of the recent residents’ meetings indicating that people have been involved in discussions about changes being made to the way the service provides choice at mealtimes and control of their own monies and or financial affairs, with the majority of the residents managing their monies with support from relatives and representatives. The residents’ meetings, as mentioned above, also provide people with an opportunity to discuss and comment on the running of the service, as do surveys, the minutes of the last meeting thanking people for completing and returning their questionnaires. In discussion with residents’ and relatives it was ascertained that one of the people living at the home arranges and delivers a weekly movement to music exercise programme, which they instigated themselves and that people take Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 17 the opportunity to go out or down to the sheltered housing complex to participate in events and socialise. The service tells us, via their AQAA that ‘our residents are empowered by encouraging them to voice their opinions at a monthly residents meeting where they discuss ideas and variation of preferences for social activities. The outcome of one meeting established the preference to meet cultural and religious needs and subsequently we provided an appropriate area for Holy Communion, lead by a lay preacher, on a weekly basis for those who wish to attend. Our residents are also supported, to run their own activity sessions, if they choose, which has proved to be popular. Staff have taught some of our residents how to use the computer we provide and now we have some regular ‘surfers’. The computer referred too within the above paragraph is located in one of the smaller lounges and according to residents’ and staff has not worked for several weeks, which again limits peoples’ opportunities to socialise and/or find stimulation. Information, taken from the residents’ surveys, indicate that people generally feel they receive both the ‘care and support they require’ and that the staff are available to help them when required, listen to their requests and respond appropriately’. The tour of the premise enable us to visit the kitchen, dining room and food storage facilities, where time was taken to speak to the catering staff. During a conversation it was established that staff felt changes being made to the menus were being recommended by us (the Commission), which we have advised is not the case and that we have produced guidance documents on nutrition within social care settings but not advice on how improvements could and should be achieved, this is the responsibility of the provider. It was clear from the comments made by both the catering and care staff present in the kitchen that they felt changes were being pushed through without appropriate dialogue having taken place with key parties, residents’, relatives and staff, etc. However, information taken from the minutes of residents’ meetings indicate that residents have been involved in discussions about changes in the menus and how choice is to be provided at mealtimes. Comments made via our surveys indicate that people feel changes in the menus would be welcomed: ‘there has been an improvement in the food but a change in the menu would help’ and comments made by relatives and service users during the fieldwork visit support the fact that people would welcome changes. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 18 The dining room is spacious and comfortable and provides adequate seating for all of the people accommodated at the home, although people can choose to dine in their rooms, should they wish. The current menu operates on a four weekly rotational basis and contains details of the main meals being served. Alternatives are available according to the catering staff, although not displayed on a menu. The service tells us, via their AQAA that ‘we recognise that atmosphere at mealtimes, the quality, presentation and type of food on offer, is a major contribution to the quality of life for our residents. We offer a person centred approach to the individual dietary needs, likes and dislikes of our service users and this information is documented in their care plan. Residents are offered a choice of menu and all meals are cooked on the premises using fresh produce to provide good old fashioned home cooked meals. Residents are also given the choice of where they eat their meals and discreet assistance is given if required. Our dining room offers a sociable atmosphere where sheltered housing tenants, family and friends often join our residents for luncheon. Our quality assurance audit shows that our service users are very satisfied with the quality and choice of food served and the activities offered. We have improved our menu system to include a visible choice of food. We have achieved a five star rating from Environmental Health’. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 19 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 & 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, and are protected from abuse, and have their rights protected. EVIDENCE: The service tells us, via their AQAA that ‘our complaints policy is displayed on the notice board in the reception area and each of our residents has a copy in a folder along with our Statement of Purpose. Individual copies can be produced in large print or translated into the service users first language. We treat any complaint seriously with the aim of taking appropriate action promptly. Our service users have the choice on how they make a complaint and to whom they make it. We offer an open culture in our home where service users and their families are supported to share any concerns they may have. We also have a whistle blowing policy for staff that may wish to report bad practice. This is actively encouraged and all staff are made aware of this at induction. Any complaint is dealt with confidentially, unless outside agencies need to be involved, then the complainant is informed that the matter needs to be taken Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 20 further and they are supported through the whole process’. During the tour of the premise a copy of the services complaints process was noticed to be on display, as stated, within the home main corridor or reception area and observations made whilst visiting people in their rooms confirmed that each person had received a copy of the ‘service users guide’ and ‘statement of purpose’ documentation. As mentioned earlier, residents’ meetings are regularly arranged and this platform provides the residents’ with an opportunity to discuss issues of concern, as evidenced by the minutes. The dataset, which forms part of the AQAA documentation, establishes the existence of the home’s complaints and concerns procedure and that this was last reviewed in the April of 2007. The dataset also contains information about the home’s complaints activity over the last twelve months: No of complaints: 3 No of complaints upheld 0. Percentage of complaints responded to within 28 days: 100 . No of complaints pending an outcome: 0. Of the two residents’ to return surveys only one indicated that they new or understood the homes’ complaints process, although this person did indicate that if they had any concerns or complaints they would raise these through their family. The service states, via their AQAA that: ‘We fully respect the human rights of people using our service. We are proactive in safeguarding our residents’ wellbeing and have policies and procedures in place, giving clear guidelines for staff. These are held in a clearly marked file in the main office. Staff are made aware of these at induction. We operate a no restrain policy in our home, but if bed-rails need to be employed to keep a resident safe, the GP or Care Manager are involved and a risk assessment is completed and recorded in the individuals care plan’. The dataset indicates that policies on the protection of service users are in place, ‘Safeguarding adults and the prevention of abuse’ and ‘Disclosure of abuse and bad practice’, both policies updated in the April of 2007. The dataset also establishes that over the last twelve months no safeguarding referrals have been made to the Local Authority, a statement that is not Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 21 support by our (the Commission) database, which established that one alert had been brought to the Commission’s and Local Authorities attention during this period, an alleged theft from a resident prompting the service to call the police, alongside notifying the Commission and Local Authority, the actions of the manager in addressing the allegations considered appropriate and satisfactory. During the visit the senior care produced copies of the homes training records, which each employ maintains individually and which demonstrated that staff have completed ‘safeguarding’ training, this corroborating the information contained within the AQAA. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19 & 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: A tour was made of the premise in the company of the senior carer. The building was found to be in a good state of repair, well decorated and furnished to a good standard within all communal areas. During the tour of the premise a vacant residents’ bedroom was visited, this was in the midst of being redecorated, which the senior care informed us was standard practice when a room was vacated. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 23 Several residents’ were visited in their bedrooms during the fieldwork visit, each room found to provide ample living space, an en-suite facility and had been furnished according to the occupants’ own design. The service states, via their AQAA that ‘Byrnhill Grove is a purpose built facility, situated close to amenities and facilities of Ventnor. We offer 16 spacious, en-suite single rooms, which our residents are encouraged to personalise with their own furniture if they wish. The residential care home is part of a sheltered housing complex and occupies part of the ground floor, sharing its communal areas. We have two assisted bathrooms and sufficient toilets within the home’. The property is well maintained and safety checks are made at regular intervals. We are compliant with Fire regulations and have recently upgraded our emergency lighting system. New lighting has been installed to the common areas to provide good illumination of the home and these areas have also recently been decorated. Our gardens are well maintained and offer a source of delight to our service users, many of whom have direct access from their rooms. We have seven profiling beds and have acquired new lifting aids, to assist with the more complex needs of our service users. Our residents all have keys to their rooms and a lockable drawer to keep their valuables safe. They have the choice to keep their door locked or not’. Records indicate that the home’s maintenance requirements are managed by an external contractor and that when issues or items need repairing and/or replacing a faxed request is made to the contractor who signs off the request as evidence of completion. Recent remedial works undertaken, according to the records included the reporting on the 26th March 2008 of two radiators that did not work, the contractors visited on the 31st March 2008 and completed repairs. Discussion with residents’ and their relatives established that people feel the environment is well maintained, clean and tidy, one person felt attention could be paid to small things, such as the quality of the linen, which they felt at times could be poor, however, generally people were pleased with the environment of the home. Responses to our survey indicate that both residents’ feel the home is ‘fresh and clean’. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 24 During the fieldwork visit a member of the house-keeping staff was observed undertaking her domestic duties, assisting care staff over the lunchtime period, clearing tables and stacking the dishwasher and generally making time to interact with the residents’. In conversation with the house-keeper it was established that she an a colleague share the duties between them and therefore provide domestic cover seven days a week. She felt that training opportunities at the home were good and discussed several courses that she had recently attended, which included moving and handling training and training on the use of chemicals hazardous to health. When asked about these chemicals and their use the house-keeper stated that within the cleaning cupboard are risk assessments and Control of Substances Hazard to Health (COSHH) data-sheets, which are provided by the manufactures and inform staff on how to handle the chemical. The service tell us via their AQAA that ‘we have proactive infection control and health and safety policies and procedures in place. Our home is kept clean and free from offensive odours, by two house-persons who share the workload over seven days. Our laundry room is equipped with commercial grade machines for coping with large volumes of laundry, which can be set to the appropriate temperatures’. The dataset, which forms part of the AQAA documentation also tells us that staff receive access to training on the management and control of infections, health and hygiene and that policies and procedures are available on the management of communicable diseases, which were last reviewed and updated in the April of 2007. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 25 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27, 28, 29 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, skilled and provided in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: The service states via their AQAA that: ‘at the request of our staff, we operate a three week fixed rota, but are flexible if they wish to swap a particular shift. We have an agreement with an agency who provide cover for sickness and absence if required. We operate a team approach to care with each team taking responsibility for key worker duties for specified service users. Each member of our staff has a job description to identify their role and responsibilities. Each team is headed by a ‘Senior Carer’ who undertakes staff supervision on a regular basis in order to identify training and development needs and best practice. We have increased the night staff to two wakeful, instead of one’. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 26 The indication from the residents’ surveys is that people generally feel the staff are available when required and that they provide the care and support they need. However, during conversations with residents’ and their relatives / visitors concerns were raised about how the staff use their time and that often they do not use free time to provide entertainment or stimulation for the service users. During the fieldwork visit three care staff were observed to be on duty, including the senior carer, which provides a reasonable carer to resident ratio. However, whilst touring the home or later when visiting residents’ the staff were conspicuous by their absence, when they might have taken the opportunity to socialise with people or attempt to develop and activities session. A copy of the staffs’ duty roster was seen during the visit, which confirmed that the home employs fifteen carers at present and has three vacancies. The roster indicates that each day shift is covered by a senior carer and two care staff and that at nights this drops to two wakeful staff. In conversation with staff it was established that at times and/or on occasions the staffing levels have been allowed to drop to two carers on duty, the result of sickness or leave and the manager’s inability to cover the shifts. Whilst no evidence of this having occurred recently could be found the manager is reminded of her responsibility to ensure the home is properly staffed at all times and that the safety and wellbeing of the residents is of paramount importance. During the visit the senior care provided us with access to the staff training files, which evidenced the courses attended by staff over the last twelve months, including: medication training, first aid, regulatory reform orders and appraisal/supervision training. Certificates, relating to the educational achievement of the staff are also retained in these files, the files being the property of the carer and therefore their responsibility to update and maintain an accurate record of their training and development achievements, several files were pointed out to the senior carer, as they required updating. The service tells us, via their AQAA that: ‘new staff undergo an induction process and have a probationary period of 24 weeks. During this time, new staff undertake the Common induction Standards training, as recommended by ‘Skills for Care’. Only when staff have been assessed, as competent, are they offered a permanent contract of employment. Once they have completed 6 months they are offered to undertake a National Vocational Qualification Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 27 (NVQ) if they have not already attained this qualification. Our Care staff group have above the required percentage [64.7 ] who are qualified to NVQ 2 and above. This is made up of 23.5 with NVQ 2 qualification and 41.18 with NVQ 3 qualification’. This information differs slightly from the dataset information, which indicates that currently the home employs eighteen care staff. Twelve of the eighteen staff have completed a National Vocational Qualification (NVQ) at level 2 or above and this provides the home with a rate of 67 of its care staff possessing an NVQ at level 2 or above. The dataset also indicates that one other person is completing their NVQ, which would increase the percentage of staff holding an NVQ level 2 or equivalent to 72 . The manager was not present during the fieldwork visit, as she was on leave. The senior care, whilst holding keys to the staff employment files was not asked to access the files for reasons of confidentiality. The senior carer did however state that no new staff had recently been employed by the service and that the home was carrying three vacancies. The manager informed us, via the AQAA that ‘our recruitment process meets the standards required to provide an structured framework for selecting suitably qualified staff to provide a balanced skill mix. Our Service users have the opportunity to participate in the recruitment of staff, by having an informal chat with the prospective candidates, when they attend for interview. Feedback from the service users is gathered and documented. This then taken into account before a decision is made. A structured list of interview questions is drawn up according to the needs of the post, and these are used for each applicant. Information contained within the dataset establishes that a recruitment and selection strategy/procedure exists to support the manager when employing new staff. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 28 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31, 33, 35 and 38. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The manager states, via the AQAA that: ‘I have been in the post of registered manager for three years and have experience as deputy manager in a larger ‘nursing’ home, with many years experience as a Registered Nurse and am currently working towards Registered Managers Awards. I keep myself updated with the knowledge and skills required for this post and have recently undertaken ‘Moving & Handling trainers’ and ‘Safeguarding Vulnerable Adults Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 29 trainers’ courses, in order to deliver in house training to my staff. I strongly believe in supporting my staff team by listening to their opinions and ideas. We are developing our supervision sessions and team building, which has resulted in motivated staff and high morale. I encourage the ethos of openness in our home, by meeting regularly with our service users both in groups and individually and by operating an ‘open door’ system, which ensures that residents, relatives and staff are able to access me easily, if they wish to’. The manager, as mentioned above, was not present during the fieldwork visit, however, the office was well organised and information required for the purposes of our visit was readily accessible, in good structural order and up to date. The staff spoken with confirmed the team care principles and/or practice introduced by the manager, with three teams of carers created, each team providing key worker support to a group of residents’. Documented evidence of the teams and the people they support was seen on display within the management office. The service tells us, via their AQAA that ‘quality assurance audit is undertaken annually, as this provides insight into how our service is viewed. It is a platform for change and gives indicators on how we can improve our service. As mentioned earlier within the report, minutes of the residents’ meetings provided evidence of the fact that a recent residents survey had been carried out, the manager using the meeting as an opportunity to thank people for completing the questionnaires sent out. During the visit, the outcome of the survey was could not be located, although it was thought that this was due to the fact that the data had yet to be complied. Records seen within the management office provide evidence of monitoring visits being undertaken by the service provider, in accordance with Regulation 26 of the Care Homes’ Regulations. These reports were informative and included a summary of the actions taken by the provider during the visit, i.e. people spoken with, premise inspections, etc. Care plans and risk assessment documents are being reviewed and updated accordingly and other records, like those relating to service users monies, etc, checked and balanced. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 30 The service tells us, via the AQAA that ‘most of our service users and/or family manage their own finances, but I have a system available to safeguard their monies and/or valuables if they request. Records are kept of all transactions’. The dataset indicates that a policy is available for the staff on assisting people manage their finances, etc: ‘management of service users money, valuables and financial affairs’, which was last reviewed and updated in the April of 2007. During the tour of the premise, people were noticed to have lockable facilities within their bedrooms, which can be used to store valuables and monies should the resident wish. As mentioned within the ‘complaints and protection’ section of this report, the service has reported one potential theft in accordance with locally agreed ‘safeguarding procedures’, the manager also notified the police and minutes of meetings and a notice on display within the home, indicate that the police have visited the home and spoken with people about keeping items safe. The service tells us, via the AQAA and dataset information that health and safety policies and procedures are made available to the staff and that domestic appliances and personal equipment is regularly maintained and serviced. Health and safety training is being made available to staff, with the training records providing evidence of the courses attended by staff, including medication training, first aid, regulatory reform orders and appraisal/supervision training. As referred to within the environment section of this report, a maintenance contract is in place and referrals are made via fax for any jobs that require attention, copies of these faxes are then signed off to confirm the completion of the job in hand. Generally the service users and their relatives are satisfied with the service being provided at the home and raised no concerns in relation to either Health or Safety issues. Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 31 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 32 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 OP12 Regulation Requirement Timescale for action 09/07/08 Regulation The manager must ensure that 12 adequate entertainment, activities and/or stimulation is made available to the service users. 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 Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 33 Commission for Social Care Inspection Maidstone Office The Oast Hermitage Court Hermitage Lane Maidstone ME16 9NT 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 Byrnhill Grove DS0000066063.V361241.R01.S.doc Version 5.2 Page 34 - 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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