Inspection on 12/05/08 for 1 Betjeman Court

This inspection was carried out on 12th May 2008.

CSCI found this care home to be providing an Good service.

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

1 Betjeman Court 31/08/06

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Aston Court Nursing Home

Polesworth Group 70 Long Street

Breme

Ravenhurst

Polesworth Group 64 Long Street

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Betjeman Court, 1 1 Betjeman Court Offmore Farm Estate Kidderminster Worcestershire DY10 3EN Lead Inspector Dianne Thompson Key Unannounced Inspection 12th May 2008 09:00 Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Betjeman Court, 1 DS0000066858.V365110.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 and Care Homes for Adults 18 – 65*. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Betjeman Court, 1 Address 1 Betjeman Court Offmore Farm Estate Kidderminster Worcestershire DY10 3EN 01562 747268 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) Sue.Brain@dimensions-uk.org www.dimensions-uk.org Dimensions (UK) Ltd Mrs Susan Mary Brain Care Home 5 Category(ies) of Learning disability (4), Learning disability over registration, with number 65 years of age (1), Mental disorder, excluding of places learning disability or dementia (1), Physical disability (1), Sensory impairment (1) Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2006 Brief Description of the Service: Betjeman Court is located in a residential area of Kidderminster and, from the outside, looks like two semi-detached houses although the interior is individually designed. The service provides residential care, for up to five adults with learning disabilities. Some people have additional physical disabilities. Betjeman Court aims to provide personal care and support that most effectively meets the needs of people using the service. This includes promoting independence and opportunities to make real choices in every day life. The service is committed to helping people achieve valued and fulfilling lifestyles. Dimensions (UK) Ltd is the care provider for the service, and details of fees are available in the service user guide. Betjeman Court, 1 DS0000066858.V365110.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 was an unannounced inspection visit to see what the home was like for the people who live there. Time was spent talking to some of the people who live at Betjeman Court and some of the staff working there. We looked at some of the policies and procedures in the office with the senior staff on duty. We talked to other people to get their views about the service. The manager completed an Annual Quality Assurance Assessment (AQAA) and sent this to the Commission for Social Care Inspection (CSCI). The AQAA is where the manager tells us about the service provided at Betjeman Court and the ways they plan to make the service better. A tour of the premises was also done. Information gathered from other sources, such as surveys, monthly visit reports and information sent to the CSCI, has been included in this report. What the service does well: Information is available about the service, and what can be provided to help people and their families to make decisions about their future care needs. People can visit and have short stays to help with these decisions. People are given help and support to make choices in their daily lives. A variety of activities are provided and people can choose to take part if they want to. Betjeman Court provides opportunities and support for people to maintain their interests and any hobbies they may have. Betjeman Court looks after people well and writes down what help everyone needs. People are supported in their medical appointments, and staff work well with other professionals and agencies to maintain the wellbeing for everyone living at Betjeman Court. Staff are trained to help them understand how to meet the needs of people who use the service and give them the support they want. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 6 Betjeman Court makes sure that suitable staff are employed and that all checks are made to keep people safe. The management team supports staff working at Betjeman Court. People are supported to keep in touch with their families and friends. Visitors are made welcome and the atmosphere in the home is relaxed and friendly. People can choose what they want to eat from the healthy and nutritious menu. Alternative options to the main menu are always provided, and snacks and drinks are available at all times. 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 Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 7 be made available in other formats on request. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Information is available about the service and what can be provided to help people and their families making decisions about their future care needs. People are given opportunities to visit and assessments are completed before people move in to make sure their individual needs can be met. EVIDENCE: Betjeman Court has policies and procedures in place for assessing potential people to live at the home. Information about the service included in a Statement of Purpose and Service User guide that is available for all enquirers and residents. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 10 There are currently no vacancies at Betjeman Court. The admissions procedure states that people would be given an information pack containing a copy of the statement of purpose and service users’ guide on admission. An updated copy of the Statement of Purpose and the Service User Guide was made available during the inspection visit and has been amended to provide information in a simpler format that people can understand. The admissions procedure states that full community care assessments would be needed and that Betjeman Court would complete their own assessments. Care plans are written from the information gathered during assessments, visits, and discussions with families and other interested parties. Surveys confirmed that information about the home is shared, and that people are kept up to date with important issues. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Quality in this outcome are is excellent This judgement has been made using available evidence including a visit to this service. Care plans provide staff with relevant information about individual assessed needs to make sure people receive up to date and consistent support. People who use the service are supported in making decisions about their lives and are provided with opportunities to participate in various aspects of life in the home. Risk assessments show how risks are to be reduced and how independence is promoted and maintained. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 12 EVIDENCE: Care plans for three people were viewed and all contained information about their needs and how they were to be met. This includes information about daily living needs, health and personal care, physical well-being, social interests and relationships, religious and cultural needs and any other specific areas, for each person. Evidence shows that care plans are regularly reviewed and action plans are agreed. Care plans are produced in pictorial formats so that people who use the service can access information more easily. For people with little or no understanding of the care plan process, statements are included that clarify this. An explanation was seen that describes how one individual is able to make decisions and the ways for staff to support this process. This is an example of good practice that is evident in all care plans seen. An action plan is agreed following each care plan review. There is evidence to show that action plans are used, followed and regularly updated. Guidelines provide staff with information to make sure that consistent care is provided. Staff said they are fully aware of the plans and follow them to guide their practice. People are allocated a key worker to oversee their care. This allows staff to work on a one-to-one basis and contribute to the care planning process for each person. Key worker meetings are held regularly and minutes of these meetings are kept. Individual risk analyses are completed to determine whether a risk assessment is required. Risk assessments are then completed to keep people safe, with suitable guidelines for assistance as necessary. This includes mobility and moving and handling. Completed risk assessments show dates for planned reviews and explore ways to make sure that people are able to be as independent as possible. Survey responses confirm that Betjeman Court provides ‘good basic care’ and that they are ‘good at trying to meet the varying needs of all the residents’. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16, 17 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 14 People are supported and encouraged to take an active part in their choice of activities. Everyone is encouraged and supported to maintain links with their families and to develop friendships. Dietary needs are well catered for with a varied and healthy menu provided. EVIDENCE: People living at Betjeman Court are encouraged and supported to make choices about activities and daily living with as much control over their lives as they are able. People make choices about how to spend their day and examples of this were observed throughout the inspection visit. Various recreational activities are offered. At the time of the inspection visit the registered manager was away on holiday with a person who uses the service. Evidence was seen in care plans to show daily routines and support given for specific interests. Activities are recorded in each persons care plan. Activities on offer include relaxation, massage, reflexology, and walks in the local area. Other activities enjoyed include swimming, shopping, music sessions, Snoezelen, and meals out. Occasional trips are arranged and seasonal celebrations are also organised. Betjeman Court has a pleasant garden and people are encouraged to spend time there, particularly in the summer. Betjeman court completes regular audits of activities that take place. From this audit the service can evaluate activities that have been enjoyed and those that were not as successful. This assists with future activity planning and demonstrates good practice. Evidence shows that regular contact with friends and family is supported. People who use the service are able to see their visitors in private, and surveys confirmed that they are made welcome. Advocates provide support where people have no relatives. Evidence shows regular support and contact with individual advocates is maintained. Relationship circles included in care plans identify who are important in people’s lives, and how relationships are to be supported. The manager states in the AQAA that people who use the service take part in ‘regional advice forums, these are 3 monthly meeting for people living in the home to air their views on the service they are receiving’. Records show that varied and nutritional meals are provided. People are offered meals, with snacks and drinks available throughout the day. People are consulted about their choice of food and diets. A discussion with staff took place about how alternative choices are made available to the planned meal. Staff confirmed that choices and alternatives are offered. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 15 Surveys confirm that the care service ‘supports people to live the life they choose’. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 16 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Individual health and personal care needs are being well met by the staff at Betjeman Court. Care plans are completed and reviewed regularly. This makes sure that staff have all the information they need to provide consistent support. Betjeman Court has a medication policy and procedure for staff to follow to ensure that all medication is administered and stored safely for the protection of everyone who uses the service. EVIDENCE: Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 17 Care plans include detailed information about each persons health needs. These plans sets out how health needs are to be met and records show that regular checks and monitoring are being carried out. Guidelines help staff provide specific support in various situations such as ‘my mobility’, epilepsy support and for using the bath lift. This makes sure that people are supported in ways they like and that all staff work in the same way. Evidence shows how information is used to make any changes to each persons support if it is needed. People have good access to medical services through their Primary Health Care team as required. This includes Occupational Therapists, Physiotherapists, Dentists and GP. A record of visits to the doctors or other medical professionals is maintained. Staff were observed providing support for people in a respectful way, making sure that dignity and self esteem was important for each person. Although communication with people who use the service may be difficult, people appeared to be comfortable and at ease in their surroundings. A policy and procedure is in place for the administration of medication. All the staff who are involved in the administration of medication receive accredited training that includes basic knowledge of how medicines are used and how to recognise and deal with problems which may occur. The manager states in the AQAA that medicine cabinets are now in place in individuals bedrooms. Medication is stored securely and given to people at the right time and full records are kept which show this. A medication sheet in each care plan gives details of current prescribed medication. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. People have access to easy to understand information about how to complain and staff support people to express their views and any concerns they may have. There are suitable procedures in place for the management of complaints. Policies and procedures are in place to make sure that people who use the service are protected from abuse. EVIDENCE: Betjeman Court has a complaints policy and procedure in place which is accessible to people who use the service and their relatives. Staff support people should they wish to make a complaint. Survey responses show that people are aware of the complaints procedure and that no complaints have been made. The manager confirms in the AQAA that no complaints have been made to the service. The CSCI has not received any complaints about Betjeman Court. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 19 As people who use the service are totally dependent upon staff for their care, staff confirmed they would advocate for people should there be any concerns. Procedures are in place that guide responses to any allegations of abuse and in managing any complaints made about the service provided. There are specific policies and procedures are in place for the protection of vulnerable adults from abuse and ‘whistle blowing’ for staff. Staff receive training in abuse awareness, and the staff on duty confirmed this. Staff also confirmed the procedures they would follow should they suspect abuse or have any concerns. Staff confirmed that people who use the service are supported in the management of their finances. A staff member said that money and accounts for people living at Betjeman Court are audited each month as part of the regular monitoring process. People are supported to keep their monies and valuables in their rooms, in a suitably locked safe. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 20 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. People who live at Betjeman Court enjoy a comfortable and homely living environment. The home is spacious and is kept clean and well maintained. EVIDENCE: A tour of the home was conducted. Betjeman Court is located in a residential area of Kidderminster and, from the outside, looks like two semi-detached houses Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 21 although the interior is individually designed. The service provides residential care, for up to five adults with learning disabilities. Some people have additional physical disabilities. There is a shared lounge and kitchen/diner and the service has specialist bathing facilities. There is a summerhouse with easy access in the garden. The lounge, upstairs bathroom and down stairs toilet have all recently been decorated. Completed maintenance requests were seen for repainting paintwork and windows, and the repairs to the pathway that are needed. Local shops and access to public transport are situated nearby. Betjeman Court has its own vehicle for people to use locally. The property is accessible, comfortable and provides a homely environment for the people who live there. The home is clean and tidy throughout. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. All cleaning materials are locked in the laundry room. Staff were observed wearing suitable protective clothing for the work they were doing, and confirmed that they are familiar with the procedures regarding the control of infection. Records show that staff have received training in health and safety matters. Additional storage and refrigerators have been arranged in the kitchen. The manager states in the AQAA that ‘the implimentation of each person we support having their own kitchen space, has resulted in a more hygienic approach to food storage’. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. There are sufficient staff on duty with the right skills and knowledge to meet the needs of people who live at Betjeman Court. Staff are well supported and work together to provide consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. Recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to ensure the safety of everyone living at Betjeman Court. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 23 EVIDENCE: Senior staff were managing the service at the time of the inspection visit as the manager was away on holiday with one of the people who live at Betjeman Court. Betjeman Court has a committed and stable staff team. Staff spoken to confirmed that the team are very well motivated and work hard to improve the lives of the people who use the service. People commented in surveys that they were generally satisfied with the service and the staff. Betjeman Court operates a recruitment policy and procedure to ensure that everyone completes an appropriate application form and that suitable references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before appointments are confirmed. All staff are required to work a probationary period. An induction checklist was seen which shows that staff cover all areas during their induction programme. It is evident that up to date training information is provided as part of Induction training for new staff, for example where the Learning Disability Award Framework (LDAF) has been replaced with the Learning Disability Qualification (LDQ). Training plans show details of all training provided and planned. The plans identify when refresher sessions are needed. These plans demonstrate good training management that makes sure all staff receive required training. Staff complete mandatory training such as Health and Safety, Fire Safety, First Aid, Food Hygiene, Moving and Handling, Infection Control and Vulnerable Adults. Staff appeared to be enthusiastic and well motivated. They stated they are well supported and are given the opportunity to share their views and opinions at staff meetings. The service is fully staffed. Staff confirmed that they have regular team meetings and minutes of these meetings are kept. Supervision of care staff includes all aspects of care practice, philosophy of care in the home and career development needs. Staff appraisals are completed annually, and staff confirmed that regular supervision takes place. The manager states in the AQAA that two more staff have been enrolled on to NVQ training. A member of staff discussed their work to complete the NVQ and the value of this training. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome are is good This judgement has been made using available evidence including a visit to this service. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 25 The service is well managed and staff receive the leadership and support they need. Dimensions monitors Betjeman Court in various ways to make sure that the health and welfare of people using the service is protected. EVIDENCE: The manager Mrs Susan Brain has many years experience working with people with learning disabilities. Susan is a qualified learning disability nurse, has completed her Registered Managers’ Award (RMA) and is an NVQ assessor. Susan regularly completes training relevant to her position as registered manager of Betjeman Court, including first aid and vulnerable adults training. Management responsibilities in the home are shared with a senior support worker. They are both involved in organising day-to-day activities, health and safety promotion, staff supervision and induction. Susan was away with a person who uses the service at the time of the inspection visit, but the inspection process was well supported by staff on duty. Staff confirmed that the manager is approachable and supportive. There is evidence that the management of the service works to planning through the Person Centred Path Map that is regularly updated. These Maps identify plans that are linked to individual plans for people who use the service. The Annual Quality Assurance Assessment (AQAA) was completed and submitted to the CSCI when requested. The AQAA is where the manager tells us about the service provided at Betjeman Court and the ways they plan to make the service better. The provider’s monthly visits are one of the ways that Dimensions monitors the service and how it is being run. These visits include interviews with staff and people who use the service. A regular audit takes place and includes records, environment, complaints received, finance and safety. Any actions that may be needed to address shortfalls are specified. The resulting reports are also part of Betjeman Court’s quality assurance and monitoring system that is intended to form an annual development plan for the service. The report includes the views of people who use the service, stakeholders and interested parties about the service that is provided. Records show that monthly checks of the fire safety system and equipment, water temperature and storage, fridge, freezers and electrical appliances are completed. Staff are undertaking all mandatory health and safety training topics. Risk assessments are carried out and recorded for safe working practices including the use of power packs for wheelchairs, and the use of slings on hoists. The records relating to accidents within the home are completed in full and are accurately maintained. Some assessments include a staff signature Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 26 list to show that people have read risk assessment. It would be considered good practice to do this for all risk assessments. The manager states in the AQAA that ‘staff have received training in risk assessment, changes to risk assessment record sheet have lead to improvements in the overall risk assessment procedure. There is evidence to show that the service has improved their management of fire safety checks and staff training. The service completes a fire instruction pack that includes a register for all staff to show that three monthly fire instruction sessions are completed. There is evidence to show that fire drills are done regularly. The manager states in the AQAA that all equipment is serviced regularly, and that ‘polices and procedures are regularly updated in line with Health and Safety and other legislation’. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 27 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. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 3 40 X 41 X 42 3 43 X 4 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 4 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Betjeman Court, 1 Score 3 3 3 X DS0000066858.V365110.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA42 Good Practice Recommendations Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT 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. Betjeman Court, 1 DS0000066858.V365110.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!