Inspection on 31/05/06 for 19 Beech Avenue

This inspection was carried out on 31st May 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

19 Beech Avenue 10/08/09

19 Beech Avenue 17/06/08

19 Beech Avenue 23/03/07

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 31st May 2006 11:00 19 Beech Avenue DS0000022536.V289377.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 19 Beech Avenue DS0000022536.V289377.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. 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 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 Position Vacant Care Home 8 Category(ies) of Learning disability (8), Physical disability (5) registration, with number of places 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 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. 9th February 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.V289377.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection to the home was unannounced and took place over the afternoon period when residents, deputy manager and care staff were met throughout the time here. A tour of the premises was made and records and administration files were assessed. What the service does well: What has improved since the last inspection? There have been efforts to implement the requirements made at the previous inspection. Enquiries have been made regarding the bathroom and professional advice has been sought this now needs to be completed. The second requirement regarding the registered Manager is being progressed. 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 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. 19 Beech Avenue DS0000022536.V289377.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 19 Beech Avenue DS0000022536.V289377.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, 2, 3, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this home. The home has procedures and documents in place that should ensure that appropriate referrals and that only people whose needs can come to live her. EVIDENCE: People’s needs had been assessed and this information informed the care planning required for each person on an individual basis. When someone new is coming to the home they would be provided with details about the services and care the home provides. This information would include the home’s Statement of Purpose and Service User Guide. These documents need to be updated and the format reviewed to make them more accessible to people. Visits to the home will include the needs of other people already living in the home so that informed decisions can be made. People had an individual written contract of the terms and conditions of the home. 19 Beech Avenue DS0000022536.V289377.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service, meeting service users, talking with staff and viewing individual records. Individual care plans identify the comprehensive individual needs of people. Staff provided attentive personal care and are informed about people’s individuality. Risk assessments are completed and promoted the safety and welfare of residents. 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 and staff are working to strengthen and develop these. This will 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. One area that needs to be reviewed is the time staff have to spend generally with residents whilst they go about other duties. There were occasions during this visit that people sat for some time without direct contact with staff. Once there is a registered manager in this full time post duties and responsibilities for staff will be again re-defined. 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 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 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this home. People’s rights are promoted and each person is supported and encouraged to be involved in life enhancing experiences. The meals in the home offer both choice and variety and cater for very specific dietary and nutritional requirements. EVIDENCE: People are supported and encouraged to maintain and develop relationships within the community. Family contact is indicated in each person’s records and this is firmly encouraged and welcomed. Staff did nurture the people in the home and promoted and supported individual participation in a positive manner. Good food and the importance of a balanced diet is an essential for people in the home and promoted their health. Specialist advice is sought in this area on an ongoing basis. 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 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 at least once during a 12 month period. 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 home. Health care matters are very 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. 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 needs. Policies and procedures for medicine management are in place and these are well organised. Medicines are stored, administered and recorded appropriately. 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 Page 12 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. There are policies and procedures in place that are designed to protect people from harm and staff are informed of these. EVIDENCE: Staff had a good understanding about adult protection matters and how to protect vulnerable people. The policy and procedures for this and for making a complaint are in place and understood by staff are not necessarily in a userfriendly format or accessible to all residents. The home are pursuing alternative ways to improve this for the benefit of people in the home. There have been no complaints made about the services and care at Beech Avenue since the previous inspection 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 Page 13 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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. Private rooms are comfortable, well maintained and provided with specialist aids and adaptations where appropriate. Communal areas are in need of some attention. EVIDENCE: People’s personal rooms are clean, pleasant environments and staff are instrumental in making these as individual and personal as possible. Specialist equipment is provided and serviced regularly. The staircase walls in the house shows some wallpaper starting to fade and peel. The entrance hall to the bungalow has chipped doors and looks somewhat dull on entering the home. The requirement regarding the bathroom made at the last inspection needs to be completed. The boards behind the specialist bath are loose and require attention. 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 Page 14 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): 31, 32, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the home. There are very committed, experienced and well trained staff that work very hard to meet people’s comprehensive needs. EVIDENCE: Staff had been very diligent in trying to balance their diverse roles and responsibilities in the absence of a registered manager. It is to their credit that personal care needs had been attended to. There are however, signs that the overall management of the home needs urgent attention. The confirmation of an appointment to this post will enable staff to resume clear roles and responsibilities again in a manner that comprehensively maintains the services of Beech Avenue as well as the care. Staff training and development programmes are in place and have been maintained. New staff had received a period of induction. The home followed the recruitment procedures for Walsingham and all staff had appropriate checks and references completed prior to commencing work. 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 Page 15 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, 38, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents benefit from the attention of a committed and nurturing staff group. EVIDENCE: The registered manager’s post has been mentioned previously in this report. The requirement that was made at the previous inspection is still in place. The home informs the Commission for Social Care Inspection of important events in the home. The unannounced visits to the home by Walsingham operations manager take place monthly and reports of these are forwarded to the Commission also. I have been kept informed of the processes taking place to appoint a manager to the home and when this is confirmed the application to become the registered manager will be processed by The Commission for Social Care Inspection. The records assessed on the day of the inspection were up-to-date. Health and Safety matters had been attended to and staff training in this had been completed. 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 Page 16 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 2 29 3 30 3 STAFFING Standard No Score 31 2 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 2 2 2 3 X X X 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 Page 17 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 YA37 Regulation 24 Requirement The service should employ a suitably qualified and experienced manager. [This is an outstanding requirement] The bathroom in the house must meet the current needs of service users. [This is an outstanding requirement] Repair the boarding behind the specialist bath. Upgrade the painting and decoration in the communal areas of the home and review the lighting arrangements in the entrance hall. Timescale for action 01/09/06 2. YA27 23 01/09/06 3. 4. YA27 YA24 23 23 01/09/06 01/09/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP 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 19 Beech Avenue DS0000022536.V289377.R01.S.doc Version 5.1 Page 19 - 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. 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