Inspection on 05/01/06 for 128 Beech Hill

This inspection was carried out on 5th January 2006.

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 no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

128 Beech Hill 14/12/06

128 Beech Hill 07/06/05

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Insight - Eastchurch

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

CARE HOME ADULTS 18-65 128 Beech Hill 128 Beech Hill Haywards Heath West Sussex RH16 3TT Lead Inspector Ms V Khan Unannounced Inspection 5th January 2006 01:00 128 Beech Hill DS0000062353.V276328.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 128 Beech Hill DS0000062353.V276328.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. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 128 Beech Hill Address 128 Beech Hill Haywards Heath West Sussex RH16 3TT 01444 239123 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) The Disabilities Trust Mrs Susan Caroline Stopa Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Commission for Social Care Inspection has agreed that Mrs Susan Caroline Stopa can be the registered manager of this service as well as Hollyrood because it is a `satellite` of the home. 7th June 2005 Date of last inspection Brief Description of the Service: Beech Hill is a satellite home connected to Hollyrood care home, which offers a service specifically geared towards meeting the needs of people within the autistic spectrum. Beech Hill is designed to meet the needs of four people with Autism and Aspergers Syndrome who are able to live a more independent life but need the support of a care home rather than supported living. The home is based in Haywards Heath in a residential area that has access to local shops and facilities. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out the unannounced inspection, which lasted a total of three and a half hours. The registered manager was not present for the inspection, but staff on duty ably assisted the inspector. One service user was out of the home for most of the inspection in a work placement. The three other service users were at home during the inspection, taking part in their structured activities. Time was spent observing staff working with service users, talking with staff and reading paperwork. Due to the complexity of the service users disabilities, the inspector was only able to engage in a conversation with one service user. The inspector learned of this person being very happy at the home and of valuing the support provided. All service users appeared to be relaxed in the company of staff and the staff were observed to provide the appropriate time and attention required by service users. What the service does well: What has improved since the last inspection? 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 6 The complaints procedure has been placed in the lounge for service users and visitors to access. 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. 128 Beech Hill DS0000062353.V276328.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 128 Beech Hill DS0000062353.V276328.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): 1 Information is provided for prospective service users and their representatives, to enable them to make an informed decision about whether or not to move in. EVIDENCE: Beech Hill is a satellite home of Hollyrood and shares the statement of purpose and service user guide. The documents describe the ethos of the home and the services and facilities provided. Copies of the service user guide and statement of purpose should be sent to the Commission, as the documents seen in the home differed to those held by the CSCI. 128 Beech Hill DS0000062353.V276328.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): 6, 7, 9 There are clear and comprehensive care plans within the service ensuring that staff are able to understand the complex needs and offer consistent care to the residents within the home. The home has a comprehensive set of risk assessments in place to ensure staff know how to support the service users. EVIDENCE: The service users plans are comprehensive and provide guidance on the specific care needed to meet the needs of each person. The care plans include any limitations due to the results of the risk assessments undertaken. Risk assessments are individualised and examples include smoking, gardening, using transport, crossing roads and using the kitchen. The service has a specific policy on the restriction of freedom. This is designed to meet the needs of the service users whilst keeping them safe. The inspector noted that a well-written report had been completed by a service user’s key worker for the statutory review. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 10 Service users are able to choose and make decisions around all aspects of their daily lives. They are involved in writing shopping lists, trips to the supermarket and menu planning. Service users are encouraged to undertake chores in the home according to a rota, to enable them to develop as far as possible, skills of independent living. Some examples of this include cleaning, changing sheets and cooking. 128 Beech Hill DS0000062353.V276328.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): 12, 13, 15, 16 Service users are enabled to engage in appropriate activities and education with an emphasis on using community based resources. Service users are supported to maintain contact with family and friends. EVIDENCE: All service users have an individualised comprehensive activity programme, which includes education. Three of the residents are following part time college courses and one service user is working in a kitchen of a local care home. Staff spoken to at the inspection had a good awareness of why service users needed such structure. The inspector observed how gentle encouragement from staff enabled one reluctant service user to participate and benefit from his scheduled activity. Service users are able to participate in activities at Hollyrood and also within the local community. Activities include local clubs, cinema, bowling, pottery, arts and crafts, music, computing, swimming, shopping, and going to the pub. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 12 Contact with family is encouraged, with service users able to receive visitors at the home and to make visits to their families. The service has a policy in place regarding guidance on contact. All contact made with the home or with service users is recorded by the home. Any relationships formed of an intimate nature by service users would be assessed as to any risks or issues of protection due to their complex needs. The service has guidance on the use of cigarettes and alcohol. One service user chooses to smoke, but consumption of cigarettes is closely monitored and can either use a designated area or go outside to smoke. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 13 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): EVIDENCE: 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 14 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 Complaints are taken seriously by the home and service users are confident that any concerns they may have are listened to and acted upon. EVIDENCE: The home has an appropriate complaints procedure that is available in a service user ‘friendly format’ using Makaton. The procedure is included in the ‘Welcome to Beech Hill Pack’ and a copy of the procedure is also held in the lounge, making it easily accessible for service users and visitors. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 15 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 Service users live in a home, which is furnished and decorated to a good standard. Risk assessments are in place which ensure the home is safe, and minimises any risks to service users. EVIDENCE: Beech Hill provides a homely environment for service users. The home has spacious communal areas including a large lounge, an activities room and a dining room. The inspector noted that the house was clean, hygienic and tidy. A good standard of décor, furniture, fixtures and furnishings were seen throughout the home. 128 Beech Hill DS0000062353.V276328.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, 35, 36 A caring, knowledgeable and dedicated staff team supports Service users. EVIDENCE: The staff files were not seen during this inspection, as they were being kept at Hollyrood. The senior member of staff on duty confirmed that they had been reorganised as per a recommendation from the last inspection. A file containing staff CRB checks was seen to be stored on a shelf in the office. The manager needs to change this practice, as the confidential documents are easily accessible to all staff members. The staff training programme is provided through Hollyrood. Staff spoken to confirmed that they are provided with plenty of opportunities for training. Examples of training includes SCIP, First Aid, Makaton, Medication, Health and Hygiene. The home also offers NVQ training to the staff as part of their development. The inspector was unable to evidence that all members of staff have attended adult abuse training. It is recommended that a review of the training needs to be undertaken to ensure that all staff receive such training. Forthcoming training in February 2006 includes Autism Focus and Aspergers Workshop, COSHH, key working, moving and handling, and report writing. The induction programme for new staff is very comprehensive. The inspector noted that there were some gaps in one induction record, and the manager is advised to pay attention to this. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 17 Staff spoken to confirmed that they felt fully supported by both the team leader and the manager. Regular supervision is provided for staff. There were some gaps in supervisor and supervisee signatures however, which could indicate that some sessions had been missed. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 18 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): 40, 41, 42 The home has a full and comprehensive selection of policies and procedures that offer guidance to the staff and help to ensure safe working practices. EVIDENCE: The Regulation 26 reports folder was read and there were noticeable gaps. Regular monthly visits and reports must be carried out, with a copy given to the registered manager and a copy sent to the Commission. The service has comprehensive policies and procedures in place. They are kept under review and updated as necessary by the manager. The inspector found the policy and procedures on infection control dated October 2005 to be clear. Matters covered include MRSA, HIV, general hazards, personal hygiene and general hygiene. Staff spoken to confirmed that they could access the policies and procedures and were aware of their use in the running of the home. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 19 Appropriate health and safety checks are undertaken, to ensure the safety of service users and staff. The last Fire Service inspection was satisfactory and no requirements were made. Records showed that the fire alarm system and the emergency lighting system were serviced in August 2005. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 20 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 3 2 X 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 X 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 X 33 X 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X X X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X X 3 2 3 X 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 21 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 Standard YA41 Regulation 26 Requirement Visits and reports need to be undertaken monthly, in accordance with this Regulation, with a copy of the report given to the registered manager and a copy sent to the Commission. Timescale for action 05/04/06 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 YA1 YA34 YA35 Good Practice Recommendations Copies of the statement of purpose and service user guide need to be forwarded to the Commission. The manager needs to ensure that any confidential information relating to the employment of staff are stored appropriately. The manager needs to undertake a review of the staff training, to ensure that all staff are trained in adult protection. The manager needs to ensure that all induction records are completed as evidence of new staff completing their induction programme. The manager needs to ensure that the supervisor and the supervisee sign supervision records, as evidence of DS0000062353.V276328.R01.S.doc Version 5.1 Page 22 4 YA36 128 Beech Hill supervision having taken place. 128 Beech Hill DS0000062353.V276328.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Worthing LO 2nd Floor, Ridgeworth House Liverpool Gardens Worthing West Sussex BN11 1RY 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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