Inspection on 15/12/05 for 11 Beechpark Avenue

This inspection was carried out on 15th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

11 Beechpark Avenue 19/02/07

11 Beechpark Avenue 13/03/06

11 Beechpark Avenue 07/03/05

11 Beechpark Avenue 02/08/04

11 Beechpark Avenue 16/02/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 11 Beechpark Avenue Northenden Manchester M22 4BL Lead Inspector Richard Dankwa Unannounced Inspection 15th December 2005 14:30 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 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 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 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. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service 11 Beechpark Avenue Address Northenden Manchester M22 4BL 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) 0161 945.6265 St Bonaventures Trust Arcon Housing Association Ltd Mrs Angela Paton Lappin Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2005 Brief Description of the Service: 11 BeechPark Avenue is a care home registered to provide personal care and accommodation for 3 adults with learning disabilities aged between 18 to 65 years of age. The registered provider is St Bonaventures Trust. The house consists of 3 single bedrooms, a staff sleep-in room, lounge, dinning area, kitchen, bathroom and a toilet room. There is a utility room outside the house for laundry. The home is wheelchair accessible with external ramps. The house is a detached building with a paved frontage and a landscaped garden to rear and side of it. It is set in a quiet residential street with houses of a similar type. It is well located for transport links by road and bus. The home is close to local shopping facilities. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and it took place on the 15 December 2005. The acting manager was present at the time of the inspection. 2 of the residents communicated well and were able to talk about the care being provided at the home. The other staff member on duty was also spoken to. The care plans for the 3 residents and some of the staff files were examined. Other records that were kept at the home were also looked at. The home had met the majority of the areas highlighted as needing improvement in the previous inspection. Other areas needing improvement were identified during this inspection visit. The Commission for Social Care Inspection did not look at all the standards during this inspection so this report should be read with the previous one to get a good picture of the service being provided by 11 Beechpark Avenue. What the service does well: What has improved since the last inspection? There were care plans in place regarding the use of when required medication that gave clear guidance to the staff as to when to administer those medications. The fire risk assessment had been updated improving the safety of the residents and the staff at the home. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 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 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 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): 2 Prospective residents were assessed before an offer of a place was confirmed. EVIDENCE: Discussion with the acting manager and an examination of individual resident’s records indicated that all residents were assessed before they were offered a place. A questionnaire was sent out to those making the referral on behalf of the resident to complete. The manager or the deputy manager visited prospective residents to assess them. A meeting would then be held involving all parties to decide whether the home will meet the needs of the prospective resident. An offer of a place was confirmed only when all parties were satisfied that the needs of the individual would be met by the home. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 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): 6, 7, 9. The changing needs and the personal goals of the residents were documented in the care plans, which allowed the staff to meet the assessed needs of the residents. The residents were treated as individuals and their independence promoted. EVIDENCE: There were detailed care plans in place for all residents, which were updated on a regular basis. The care plans included risk assessments and plans as to how to manage challenging situations. Discussions with individual residents pointed out that they made decisions about their lives on a regular basis. They chose what to eat, where to go, the activities to participate in, the programmes to watch on the television, what to wear, etc. The residents were treated as individuals and they were encouraged to take risks as part of their independent lifestyle. Some of the residents went to the local community on their own using known routes. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 10 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): 12, 13, 14, 15, 16, 17. The residents participated in appropriate leisure and cultural activities in the house and also in the local community. The home encourages the residents to have relationships. The home provides the residents with healthy balanced diets. EVIDENCE: Examination of resident records revealed that they participated in age, peer and culturally appropriate activities such as attending college and adult training centres. They were supported to go to the town centre to withdraw money to pay their bills and buy personal items. Some attended Saturday clubs. All the residents visited the local community on a regular basis to use the local facilities such as restaurants and shops. They also use the local bank to draw money. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 11 There was a planned programme of leisure activities in place that the residents were encouraged to participate in. They enjoyed bowling, disco, pubs, riding in the mini bus to visit places of interest, jigsaws, aromatherapy, art, and going out for walks. One of the residents was assisted to watch the football team he supports. All the residents recently visited Trafford Centre to celebrate one resident’s birthday. Observations during the inspection between the residents and staff indicated that the residents were treated with respect. The residents commented how well they were treated and supported by the staff team. The residents were encouraged to clean their bedrooms and participate in general household chores. There was plenty of fresh food available for the residents. The staff stated that the residents were offered choice during meal times. A record was kept of food served. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 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): 18, 19, 20. The residents received personal support in the way they preferred. Residents’ physical and emotional needs were documented in the care plans allowing staff to meet the assessed needs of the residents. The medication procedures were adequate to meet the needs of the residents. However, the new guidelines had not yet been implemented. EVIDENCE: Observations during the inspection visit indicated that the residents were treated in a dignified manner. All residents had individual plans specifying how they should be supported and cared for. The residents received specialist input such as the behavioural specialist to assist the home to put individual care plans in place. All the residents had access to a local General Practitioner. The residents also had access to a dentist. There were policies and procedures in place to manage medication. None of the residents managed their medication. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 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): 22, 23. There were policies and procedures in place for managing complaints. The policies and practices of the home ensured that the residents were safeguarded from abuse and harm. EVIDENCE: There were policies and procedures in place that were signed and dated by all staff. The procedure was displayed in a prominent place. The staff present during the inspection stated that they were aware of how to make a complaint. The home had policies and procedures for the promotion and protection of residents from harm or abuse. All staff had read and signed the policies and procedures. There was a Whistle Blowing policy in place. The staff that were spoken to during the inspection were aware of how to deal with allegations of abuse. However it is recommended that formal training be provided on the protection of vulnerable adults. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 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, 30. The residents lived in a clean, homely, comfortable and safe environment. EVIDENCE: The residents lived in a home that was warm and welcoming. The home was nicely decorated and the bedrooms were personalised to individual resident’s taste. Fabrics were updated on a regular basis. The curtains in the lounge had recently been replaced. The residents enjoyed a home that was clean and tidy. There was no presence of offensive odour. The grounds were kept clean and free from hazards allowing the residents to enjoy the garden. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 15 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): 32, 34, 35. The home ensures that the right staff are employed to look after vulnerable people. This means that the residents are safeguarded by the recruitment practices of the home. EVIDENCE: All the staff had completed NVQ Level 2. Some of the staff undertook Level 3. Staff records indicated that the staff received specific specialist training such as Understanding Sight Loss. The home had recruitment policies and procedures in place to safeguard the interest of the residents. All staff had a Criminal Records Bureau check (CRB) and a Protection of Vulnerable Adult check (POVA) before they started working. Examination of staff files pointed out that they had received induction, health and safety awareness, food hygiene, manual handling, First Aid, control and restraint, handling and administering of medication. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 16 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. The home was well run by the acting manager. The residents’ views were not taking into account in the self-monitoring and development by the home. The home had policies and procedures in place to promote and protect the wellbeing of the staff and residents. EVIDENCE: The acting manager was running the home well. The residents and the staff were able to approach her with any issues and they were dealt with appropriately. The acting manager was hoping to complete NVQ Level 4 early this year. Discussion with the residents and the staff indicated that the opinions of the residents were being actively sought and taken into account in the selfmonitoring, reviews and development by the home. However, no record has been kept of these consultations and this needs to be addressed. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 17 There were health and safety policies and procedures in place to promote and protect the residents from harm. Fire tests were carried out on a weekly basis. Moving and handling training was offered to the staff and was ongoing, which allowed the staff to handle the residents appropriately. Equipment checks were being carried out at suitable intervals. Gas and electric safety checks were carried out and there were certificates available for inspection. An accident logbook was in place and the accidents were audited on a regular basis. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 11 Beechpark Avenue Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X 3 X DS0000029483.V271833.R01.S.doc Version 5.0 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 YA39 Regulation 24 (3) Requirement The registered person must ensure that a quality assurance system is in place that allows for the recording of consultations of the residents and their representatives. (Timescale of 04/07/05 was not met). Timescale for action 28/02/06 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 Refer to Standard YA41 Good Practice Recommendations It is good practice for staff to use black markers for documentation rather the use of red or blue markers. 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 11 Beechpark Avenue DS0000029483.V271833.R01.S.doc Version 5.0 Page 21 - 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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