Inspection on 23/03/07 for 19 Beech Avenue

This inspection was carried out on 23rd March 2007.

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 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

19 Beech Avenue 10/08/09

19 Beech Avenue 17/06/08

19 Beech Avenue 31/05/06

19 Beech Avenue 09/02/06

19 Beech Avenue 26/10/05

19 Beech Avenue 19/11/04

19 Beech Avenue 17/05/04

Similar services:

Dystlegh Grange

The Good Companions

Cuerden Grange Rest Home

Springfield Cottage

Parkside

Park Lodge

Ruskin Lodge

Clover House

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

CARE HOME ADULTS 18-65 19 Beech Avenue Smithfield Egremont Cumbria CA22 2QA Lead Inspector Cath Wilson Unannounced Inspection 23 March 2007 10:00 rd 19 Beech Avenue DS0000022536.V319683.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 19 Beech Avenue DS0000022536.V319683.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 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. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 19 Beech Avenue Address Smithfield Egremont Cumbria CA22 2QA 01946 824885 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) beechavenue@walsingham.com Walsingham Post Vacant Care Home 8 Category(ies) of Learning disability (8), Physical disability (5) registration, with number of places 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Registered for 8 people over 18 years of age with a learning disability (LD) of whom 5 may also have a physical disability (PD). The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 31st May 2006 Date of last inspection Brief Description of the Service: Walsingham provide the services and care at 19 Beech Avenue. Eight service users who have a learning and physical disability can live in this home. The home is located in a residential area about one mile from the town of Egremont on the West Coast of Cumbria. Operating as one unit, it comprises of a bungalow and adjoining house. Both properties are linked by a covered and secure walkway. The properties blend in naturally with the immediate area. All private bedrooms are for single occupancy. Those in the bungalow all have en-suite shower, toilet and washing facilities. There is a range of adaptations and specialist equipment available. The bungalow is designed to enable service users who use wheelchairs, and who may need additional support to move around with ease 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second Key Inspection to this home following a previous random visit and first Key Inspection. This was in order to follow up the requirements that had been made and to re-assess the overall outcome rating for this service. During this time all the key standards of the National Minimum Standards were re-examined. I was able to meet with the manager and service users and assess the agency’s policies, procedures and staff and service user’s records and documentation. Prior to this visit questionnaires had also been sent out to service users and their relatives. These were also used to obtain their views of the services and care provided. The manager had completed a pre-inspection questionnaire and this assisted in verifying information throughout this inspection. What the service does well: Detailed documentation is available about the services and care provided. Positive steps are taken to make these appropriately accessible to people. The manager and staff have the best interests of people in mind throughout their work. As one relative commented ‘ the care is excellent and I am made to feel at home when I visit’. Are keen to improve means of interpersonal communication and enhance the lives of people in the home. The manager and staff seek the views, advice and skills of other related professional personnel to achieve this. Staff training and development programmes are comprehensive and kept up-to-date. The manager and staff work very hard to maintain a comfortable home for people and do so with the best interests of service users in mind. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 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 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The information available to prospective residents, their family or representatives is well documented. The Statement of Purpose and Service User Guide are regularly reviewed and currently being updated. Both documents are accessible and available to family and representatives also. The home’s use of photographic and symbols in their documentation is being developed. This further involves residents in everyday events in their life and positively includes them in this. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The manager and staff are very focussed on achieving the individual outcomes for people. Risk taking is well managed and a good balance is achieved in promoting the well being and safety of people. EVIDENCE: The care planning used in the home is kept up-to-date with the use of daily records and staff meeting from one shift to another. The care plans identified people’s complex needs. The care planning system is currently being strengthened and developed. This will then clearly identify the actions needed and taken to meet the outcomes for people and identify when these had been achieved. Staff were very diligent about ensuring people were comfortable and their physical needs attended to. Risk assessments are undertaken and these too are being reviewed so that they are fully integrated into the care planning practices. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s rights are very much promoted and their individuality respected. Meal times are also catered for on an individual basis both in the home and through using community. EVIDENCE: People’s leisure and community involvement are detailed in their personal record and staff are very encouraging and supportive of people attending these. Staff attended to these in a manner that respected people’s individuality and planned people’s inclusion with this in mind. Family members are encouraged to have involvement. Mealtimes are arranged to meet individual need whether this be in the home or community. Staff encourage and support people and their rights and choice are recognised and promoted. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care matters are well managed and great importance is placed on the health and safety of people. Arrangements for medicines management also promoted people’s safety and well-being. EVIDENCE: Staff had a very good understanding of people’s complex healthcare needs. This information is detailed in their records. There are well-developed relationships with community health care resources. Specialist advice, guidance and treatment had been included in this provision to ensure people’s health care requirements are responded to. Health care needs are routinely monitored, as is the medicines management in the home. As stated previously the care planning that is being developed includes health care matters and recording the outcomes in a progressive manner. There are skilled staff in the home who are experienced in supporting people with a physical and or a learning disability and had very good understanding of people’s healthcare 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 Page 12 needs. Policies and procedures for medicine management are in place and these are well organised. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s complaints system is available to both service users and their family and arrangements for safeguarding adult procedures in place. EVIDENCE: Information is available regarding complaints and service users, relatives or representatives have access to this. Staff are informed of the policies and procedures relating to safeguarding adults and how to safeguard the health and welfare of people in the home. Safeguarding adults is integrated into the training and development plan for each member of staff. The manager and staff are familiar with the multi-disciplinary guidance and include arrangements for training to be appropriately renewed. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Private rooms are comfortable, well maintained and provided with specialist aids and adaptations where appropriate. EVIDENCE: People’s personal rooms continue to be clean, pleasant environments and staff are instrumental in making these as individual and personal as possible. Specialist equipment is provided and serviced regularly. Matters that have been raised in previous inspections are being implemented. The sensory room is in the process of being upgraded, as are arrangements for improving the décor in the communal areas including doors and framework. The specialist chairs used by people in the home are being re-assessed. The requirement regarding the bathroom improvements has been completed. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32 33 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a motivated and committed manager and staff team that are focussed on meeting people’s needs. EVIDENCE: Staff continue to be provided with a good training and development programme and the manager and staff are pursuing additional training issues so that they can enhance the lives of people in the home. The manager and staff are well informed of the needs of people and certainly have great commitment to placing their needs first and provide them with life enhancing experiences. Their training needs are identified and they are supported and encouraged in their work. Looking at ways to make information user-friendly and more accessible is an ongoing process for them but these are all examples of good care practices. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People continue to benefit from a service that places their personal needs first and where they are valued as individuals. EVIDENCE: There are health and safety policies and procedures available in the home and staff are informed of these matters. The records assessed on the day of the inspection were accessible and confidentially stored. The manager is very focussed in her responsibilities and is working to implement and maintain records and documentation systems in the home that would benefit service users life styles. The manager now needs to proceed with her application to be registered as manager with the Commission for Social Care Inspection. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 Page 17 Arrangements in the home were very focussed on meeting the needs, wishes and aspirations of the people living here. 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 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 Standard No Score 1 2 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 2 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 Page 19 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. 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. Refer to Standard Good Practice Recommendations 19 Beech Avenue DS0000022536.V319683.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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. 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