Inspection on 10/02/06 for 10 Beeches Road

This inspection was carried out on 10th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

10 Beeches Road 23/02/07

10 Beeches Road 31/10/05

10 Beeches Road 01/03/05

10 Beeches Road 16/11/04

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Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 10 Beeches Road Rowley Regis West Midlands B65 0BB Lead Inspector Mr Jon Potts Announced Inspection 10th February 2006 09:45 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 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 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 10 Beeches Road Address Rowley Regis West Midlands B65 0BB 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) 0121 559 4384 N/A Inshore Support Limited Bhanisha Patel Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/10/05 Brief Description of the Service: 10 Beeches Road is home for two physically able younger adults who have a learning disability with additional mental health needs. The home is an extended two bed roomed terraced property near the centre of Blackheath, sited in an established residential area. The house offers a choice of lounge areas, a reasonably sized kitchen dining area and two large single bedrooms, one a full en-suite. The property is generally well presented and is furnished in a domestic style. The home only accommodates long stay placements and does not accept emergency admissions. The residents are currently male but the home will accept referrals from either gender. The home does not cater for adults with mobility difficulties. The mission statement of the home is to support the individual to attain personal independence, choice and responsibility in a homely environment which expresses unconditional acceptance and tolerance and is committed to friendship and growth 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was carried out between 9.45am and 12.55pm and involved the registered manager and discussion with staff. The inspector met both residents. Information/evidence was drawn from limited case tracking, staff files; sight of documents, policies and procedures, a pre inspection questionnaire, comment cards from relatives and through discussion with the manager and staff. What the service does well: What has improved since the last inspection? What they could do better: There is a need to develop personal care planning in the form of resident’s individual books, although to enable staff to be able to commence this work appropriate training needs to be provided for staff. The home needs to send out questionnaires for stakeholders such as social workers, health authority staff and such like in addition to those completed with residents and sent to relatives. The manager also needs to ensure that staff complete separate records in respect of any injuries to residents that may be as a result of restraint. The homes porch needs to be redecorated or refurbished. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 6 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. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 Each service user has an individual written life style agreement with the home. EVIDENCE: There was evidence in case files of residents having a contract (called a lifestyle agreement) this setting out terms and conditions as well as costings in respect of the individual service users care. Whilst the actual contract is not at this time in pictorial format there is a pictorial summary of the tasks the staff are to complete for the service user, and the contracts were seen to be signed by the resident’s relatives. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 10 Residents were seen to be supported in making decisions about their lives. Information about residents is handled appropriately with practices in place that preserve confidences. EVIDENCE: The residents’ were seen on the day of the inspection to be involved with making day-to-day decisions with the assistance of the staff on duty and there is documentation in place in the form of risk assessments and more recently, information on limitations that details where residents involvement maybe limited. Relatives are involved, one indicating via comment card to the CSCI that they are kept informed (and both stating this on written comments to the home) and regular reviews by the resident’s social workers were also seen to consider the way in which residents are to be supported in the decision making process. The funding bodies and parents have involvement in the resident’s financial affairs, with the home not acting as an appointee. The home was seen to have appropriate policies and procedures in respect of handling of residents information with a clear statement in the case files to inform as to who will have access to the information. The use and handling of 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 10 information is covered in the induction training for staff, this received by them early on in their employment. There was evidence seen from sight of the case files of one services users signature on some documents. The organisation is known to have communicated its stance on confidentiality to other organisations in the recent past. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above outcomes were fully assessed at the time of this inspection. EVIDENCE: See above comments 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 Staff were seen to be promoting the meeting of residents physical and emotional needs. EVIDENCE: There was clear evidence that the residents were assisted to access health services whether specialised or pertaining to routine health not associated with their learning disability. One of the residents had not however seen a dentist recently, although it was evident that the staff at the home were trying to source one, this evidenced by phone calls to dentists on the day of the visit. An appointment for a home visit by a dentist was stated to have been set up for a date prior to the inspection, but the dentist had not attended. There was evidence that staff had involved the resident with these services in the past, with a dental care plan available in the resident’s case file. On the basis that there was evidence that the staff at the home were making every effort to address this outstanding issue the inspector has judged the home to be meeting the standard on healthcare. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of the above outcomes were fully assessed at the time of this inspection. EVIDENCE: See above comments. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 10 Beeches Rd is a comfortable and overall safe environment that is suitable for the residents accommodated. The resident’s bedrooms are suitable for individual lifestyles, bathrooms and toilets promote privacy, and shared spaces complement and supplement their needs. EVIDENCE: The home is sited in a suitable position and presents as a homely environment in keeping with the provision of ‘normal’ domestic style living. There is no indication that the house is anything other that a domestic home, this ensuring that it blends into the immediate community. The home has a redecoration and refurbishment programme identifying works, although it was noted that the exterior woodwork to the porch does need attention, this to be painted or as stated by the manager as planned, replaced with UPVC. All other windows in the house are now UPVC double-glazed. The tiles at the rear of the cooker have now been replaced with a stainless steel panel. All the communal living areas within the home presented as being comfortable and clean. The residents were seen to have access to very large single bedrooms, these very well presented and accompanied by en suite facilities. This coupled with the space available to the resident’s downstairs means that there is ample 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 15 scope for privacy. There is also a garden available to residents at the rear of the house. Neither of the residents have any physical disability and the physical environment is appropriate for their current needs 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 There was evidence that the homes recruitment practice has improved and that residents are now better protected as a result. EVIDENCE: The files for three recently employed staff were examined and these showed that all appropriate recruitment checks had been completed with the exception of the following: • Two of the files had gaps in respect of the staff members working history. One of these gaps was due to a missing page in the application form, which the manager thought was due to this page not having been forwarded by the head office. The member of staff concerned did confirm that they had completed this information. • One member of staff was employed prior to receipt of a POVA 1st check, this however in May 2005. The staff employed more recently had received their POVA 1st prior to employment, with risk assessments discussed with the CSCI as appropriate. Care must be taken to ensure that this matter does not arise again. Interview records were seen to be present for all three members of staff with Scoring of their performance against standardised questions. There is a need for staff to receive training in personal care planning to assist with the development of PCPs for residents. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 Resident’s benefit from a well run home. The views of residents and relatives are taken into account by management. Self-monitoring of the service is also improving. The health, safety and welfare of residents is promoted and protected. EVIDENCE: The manager has recently been registered having evidenced her ‘fitness’ to the CSCI for the role of manager at 10 Beeches Rd. The manager is in the process of completing the appropriate managerial training. The home was seen to have a system for monitoring where by a manager from head office visits the home on a monthly basis to carry out an audit on a number of standards. This has shown to be effective in identifying a number of issues and indicates that the organisation is moving towards better selfmonitoring although the standards that are currently assessed would benefit from expansion (this a matter in respect of which senior manager’s are 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 18 consulting with CSCI). The home was seen to have regular consultation with residents and relatives via questionnaires although this would benefit from expansion to include the full range of stakeholders for the service such as social services departments, health personnel and so on. There was a clear business/development plan available, with evidence of the home working towards reaching identified aims although this needs to be available to all the users of the service in an abbreviated format, this report also to include findings from consultation exercises. Various record in respect of safe working practices were sampled during the course of the inspection this including accident books, other inspection bodies reports, training records, risk assessments and maintenance documentation. The documentation was found to be to a good standard and was consistent with policies and procedures. There were no obvious hazards seen to resident’s safety during the course of the visit. There was two accident reports that contained information as to a slight injuries (friction burn/graze) received by a resident during a restraint. The manager was advised to maintain separate records of such. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 3 25 4 26 4 27 4 28 4 29 4 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 X X 2 X 2 X X 3 X 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 20 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA24 YA34 Regulation 23(2) b 19 Requirement The exterior woodwork to the Porch requires redecoration. Staff application forms must consistently contain details of the staff member’s full working history. To provide staff with appropriate training in personal care planning. To continue developing the homes systems for selfmonitoring. Timescale for action 30/06/06 15/03/06 3. 4. YA35 YA39 18 24 30/06/06 30/06/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA37 YA39 YA42 Good Practice Recommendations The manager should continue with her training in respect of NVQ 4 in management. To seek the views of any stakeholders for the service through such as questionnaires and make these views available to others in a public report. To detail any injuries due to restraint in a separate record. 10 Beeches Road DS0000040084.V275288.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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