Inspection on 12/08/08 for 2 Beech Close

This inspection was carried out on 12th August 2008.

CSCI found this care home to be providing an Adequate service.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Extracts from inspection reports are licensed from CQC, this page was updated on 12/11/2008.

CARE HOME ADULTS 18-65 2 Beech Close 2 Beech Close Dunstable Beds LU6 3SD Lead Inspector Nicky Hone Unannounced Inspection 12th August 2008 11:10 2 Beech Close DS0000071734.V365015.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 2 Beech Close DS0000071734.V365015.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. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 2 Beech Close Address 2 Beech Close Dunstable Beds LU6 3SD 01582 662661 01582 662038 gladysquinn@tactltd.org 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) TACT UK Ltd Mrs Gladys O Quinn Care Home 8 Category(ies) of Learning disability (8) registration, with number of places 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is 8 This is the first inspection of 2 Beech Close since it transferred to TACT UK Ltd. The last key inspection was on 21/06/07. 2. Date of last inspection Brief Description of the Service: 2 Beech Close is a home for up to eight male adults with learning disabilities. On 01/03/08 TACT UK Ltd took over as provider of the service from the Bedfordshire and Luton Mental Health and Social Care Partnership Trust (BLPT). The bungalow is owned by the MacIntyre Housing Association (MHA), which is responsible for the maintenance and upkeep of the building. The bungalow is situated approximately one mile from Dunstable Town Centre. It shares a site with two other registered care homes, where the service is also provided by TACT, and a resource centre owned by the NHS. The bungalow has eight single bedrooms, two lounges, a dining room, kitchen, laundry and bathing facilities. There is a fair-sized, enclosed garden to the rear of the property, with adequate parking to the front and side of the building. The home provides its own transport. Full information regarding the fees, including any additional charges, was not known at the time of writing. From the documents we looked at, it would seem that the people who live here know what rent they pay to the Housing Association, but do not know the full cost of their care. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. TACT UK Ltd. took over as provider of the service at 2 Beech Close from the Bedfordshire and Luton Partnership Trust (BLPT) on 1st March 2008. The building is owned and maintained by MacIntyre Housing Association. At the time of this inspection there were six men living at 2 Beech Close. Following our inspection in June 2007, we (the Commission for Social Care Inspection) rated 2 Beech Close as a ‘poor’ (0 star) service. We carried out a random inspection on 22/02/08, when we looked at standards with a safeguarding theme. We sent a letter to the provider following the inspection, telling them about the issues we raised with the manager. We did not write a full report, or make any requirements, because the service was about to transfer to the new provider. For this inspection (12/08/08) we looked at all the information that we have received, or asked for, since the last key inspection of 2 Beech Close. This included: • The AQAA (Annual Quality Assurance Assessment) that the manager completed and sent to us in May 2008. The AQAA is a self-assessment that focuses on how well outcomes are being met for people living at the home. It gives the manager the opportunity to say what the home is doing to meet the standards and regulations, and how the home can improve to make life even better for the people who live there. The AQAA also gives us some numerical information about the service; Surveys which we sent to the home to give to people who live at 2 Beech Close, to their relatives/carers, and to staff. We received 13 replies: 3 from residents; 4 from relatives; and 6 from staff. Some of the comments from the surveys, and some of the results are quoted in the summary and in the body of the report; What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement; Any safeguarding issues that have arisen; and Information we asked the home to send us following our visit. • • • • 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 6 This inspection of 2 Beech Close included an unannounced visit to the home on 12/08/08. We met all six of the people who live at the home, and observed the way staff were supporting them. Most of the people who live here do not use many words to communicate, so they were unable to tell us much about their home. One relative returned our questionnaire and asked us to telephone them, which we did before the inspection. This person was very positive about the care the home gives to their relative. At the time of this inspection, the registered manager, Gladys Quinn, had been seconded to manage 1 Beech Close, and Bob Bradley had been appointed as acting manager at 2 Beech Close. However, Mr Bradley was on holiday, so Ms Quinn was managing both services. We spent time with Ms Quinn, and spoke with some of the staff. We also looked at some of the paperwork the home has to keep. This included care plans, risk assessments, medication charts, and records such as staff personnel files, staff rotas, menus and fire alarm test records. What the service does well: All six of the people who live at 2 Beech Close have lived together since the home opened, over 10 years ago. They are now very settled and comfortable living together. When they are at home, all six people like to spend most of their time in the shared areas of the home, and the house feels quite busy and full. For these reasons we would be quite concerned if there were plans to move two more people into the vacant bedrooms, as new people could easily upset what is currently a pleasant and happy atmosphere, and make the group far too big. We spoke to one person’s relative, who said “It’s his home, he’s very very happy and he always wants to go back [after visiting us]”. This person also said “I’m very happy, and I’m happy with whatever they do for him”. One relative who sent back one of our surveys wrote, “My relative is looked after very well. He’s very happy there and always looks nice and clean. We are very happy how the home is run”. Another wrote, “(name) is very happy where he is and so are we”. And another “My relative has always been happy at Beech Close”. Most of the staff who returned the surveys were positive about all aspects of the service. One staff member, when asked what the service does well, wrote “supporting people to better their lives, communication, team work and induction and training for staff”. We saw that the people who live at 2 Beech Close get on well with the staff, and there was a relaxed, comfortable atmosphere in the home. There is good information available about the home, and people’s needs have been thoroughly assessed. Support plans give good, detailed guidance to staff 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 7 on the way each person wants to be supported, and risk assessments are recorded so that people can be supported to take reasonable risks. The opportunities for people to develop skills, and for educational and leisure activities have improved since our last inspections, and the menu showed that people have been supported to choose food they like to eat, resulting in a balanced, nutritious and reasonably healthy diet being offered. People see healthcare professionals, such as doctors, chiropodist, optician and so on when they need to, and medication is handled safely so that people get the medicines they need. The complaints procedure is up to date and easy to understand and staff have been trained in safeguarding so that they know how to keep people safe. The home is kept reasonably well maintained and decorated and on the day we visited was clean and smelt fresh. Staff are recruited well, and most staff have done all the basic training, such as moving and handling, first aid, and food hygiene. Most of the time there are enough staff on duty to make sure people’s needs are met. 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. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 8 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 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 9 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, 2, 3 People who use this service experience adequate quality outcomes in this area. There is good information available about the home, and the people who live here know their assessed needs will be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: 2 Beech Close has a statement of purpose and an updated service user guide, which uses pictures so that people who live at the home are more able to understand what it is about. It gives good information about the service provided. We looked at the records the home keeps about two of the people who live here. There was a detailed, up to date, assessment on each file of the person’s needs and the ways in which he needs to be supported. Because these people have lived at 2 Beech Close for many years, the original assessments would not be relevant, so these new assessments were done when it was planned the home should transfer to a new provider. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 10 We did not see a contract, or statement of terms and conditions of residence on the files we looked at. We did not see any thing that would give people clear information about the total amount they have to pay for the care they receive, and how this is covered by benefits. Since the inspection we have been told that a contract was in place on one of the files we looked at, but that the contract contained no information about fees. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 11 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, 8, 9 People who use this service experience good quality outcomes in this area. Care plans and risk assessments contain good information and guidance for staff so that they can meet the needs of the people who live at 2 Beech Close. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: We found support plans for both people on the records we looked at. The plans have been developed from the assessments, and a new format for the plan was being used, based on ‘person-centred’ care. The support plans included very good, clear, detailed information about the way each person likes to be supported for all aspects of their personal care and their daily routine. The guidelines also included goals for all areas of daily life, for example washing, dressing, getting breakfast and so on. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 12 Risk assessments were in place, and there were clear behaviour management guidelines for staff, detailing the person’s behaviour, what to do and what not to do. One person’s behaviour had indicated he might prefer to have male staff. This had been tried and the person was much calmer and seemed much happier, so rotas now try to ensure there are always male staff on duty. People who live at 2 Beech Close are invited to attend a monthly meeting, when they are asked for their views on a number of aspects of their home. The minutes we saw showed that subjects discussed included holidays, diet, outings and exercise. Pictures are used in the minutes so that everyone is able to better understand them. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 13 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): 11, 12, 13, 14, 15, 16, 17 People who use this service experience good quality outcomes in this area. People are offered a range of educational and leisure opportunities so that they can lead full, satisfying and interesting lives. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People who live at the home are being supported by staff to develop their daily living skills and become more independent. There is a possibility that some people might move to supported living at some time in the future, so staff told us they want to be sure people will be able to do as much as they can for themselves. Each person who lives at 2 Beech Close has an activity plan which includes education, leisure activities and community involvement. One person’s we 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 14 looked at showed that he has a very busy week planned. Records showed that in the first 11 days of August he had been out for at least one activity on 8 days. The second person whose records we were looking at had been out on 9 of the first 11 days, including going out twice with his brother. However, we also noted that records showed people did not always do what was on the plan. For example, the day before we visited, the plan for the afternoon for one person was ‘drive in country or Whipsnade zoo’: the record stated ‘stayed at home wandering in and around garden’. On the day of the inspection the morning plan was that he should ‘shop for bread and milk’, but he did not go out. There was no particular reason for these activities being missed. The manager said the staff team has been working hard to find different activities that people would enjoy and which would have some meaning for them. She felt activities have improved, but there is still some way to go. In the AQAA the manager told us that each of the people who live at 2 Beech Close has a bus pass and they use local buses more than they used to. The assessment we saw for one person stated that he should be supported to access more community settings, for example swimming, bowling, music and so on. Staff are working on this and trying to overcome some of the barriers created by the person’s behaviour. Holidays have been planned for people who want to go away. 2 people had been supported to arrange a holiday in Skegness. Daily notes for one person showed that he has been encouraged and supported to learn how to take part in some of the household tasks, such as cleaning, laundry, and preparing for meals. Each Sunday the residents choose what they would like on the menu for the following week. The staff and residents have put together a box containing a huge number of pictures of different food and meals, which the residents make their choices from. The menu showed that people are offered a nutritious diet which includes as many ‘healthy’ options as possible. Staff record on the daily notes what people have had to eat each day. One member of staff told us that the person who is diabetic knows what he should eat: he will push food away if he does not want it, or knows he should not eat it. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 15 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, 20 People who use this service experience good quality outcomes in this area. People’s healthcare needs are met and medication is handled safely so that people are supported to be as healthy as possible. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Guidance for staff in people’s support plans showed that people are offered personal care in a very person-centred way. People decide how and when they want their personal care, and this is detailed in their support plans, which are written in a ‘person-centred’ way. In the records we looked at we found evidence to show that all aspects of each person’s healthcare are monitored. For example, one person needs regular checks on his ears, and blood tests to monitor his diabetes. The records showed that people see the chiropodist when they need foot care, have appointments with their doctor, and their medicines are regularly reviewed. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 16 One person’s records showed that staff had referred him to a psychologist and were now following the psychologist’s advice and guidelines. Each person has a separate folder containing information about their medication. The two folders we looked at contained consent for staff to administer the person’s medication, either from the person’s relatives or from their doctor. The Medication Administration Record (MAR) charts we looked at were all signed correctly, with medication being checked in, and signatures when the medication had been administered. Medication had been given as recorded. The folders contained clear guidelines for staff on how and when to give ‘when required’ medication, and how it should be recorded. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 17 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, 23 People who use this service experience good quality outcomes in this area. People who live here, and their relatives, have been given information about how to complain, and they can be confident that staff have been trained to make sure they are safeguarded from harm. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The home has a complaints procedure, and a brief guide to let people know how they can complain about the home if they want to. The guide uses a number of pictures in the hope that the people who live here will be able to understand should they wish to make a complaint. In the AQAA the manager stated that no complaints had been received in the previous 12 months. The organisation has introduced a new way of keeping people’s money safe, which is a great improvement. Each person has a pouch with a small amount of their cash which is kept in the safe. The pouch is sealed with a numbered seal, and checked and re-sealed each time any money is taken out. Each person has their own bank book. One new staff member we spoke to told us that safeguarding had been covered in his induction. He was clear about abuse and what to do if he suspected that anyone might be being abused. Staff training records showed that all staff have received safeguarding training. Policies and procedures are kept in the office so that all staff know where to find them quickly if they need to. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 18 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, 27, 28, 30 People who use this service experience good quality outcomes in this area. 2 Beech Close is reasonably well decorated, furnished, maintained and cleaned so that people have a comfortable, homely, hygienic and pleasant place to live. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Generally, the decorating and maintenance of the home has improved since our last visit. Some more personal items have been added to some of the bedrooms so they are beginning to look more individualised to each of the people who live at the home. The activity lounge has a lot of equipment for people to do in-house activities, such as jigsaw puzzles and games. The shared areas of the bungalow are reasonably decorated and the furnishings are quite comfortable so that people have pleasant surroundings to live in. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 19 The flooring in the bathrooms and kitchens was badly stained, in spite of being cleaned. This flooring is not suitable and will have to be replaced. The Housing Association are aware of this (it was a requirement following our inspection in June 2007), but the replacement is taking a long time. Keys to people’s bedrooms have been moved from the lounge so that each person has a key for his bedroom in his wardrobe if he wants to use it. Outside there are enclosed gardens at both the front and rear of the bungalow. The front gate is no longer kept locked so people are able to leave the bungalow if they want to. Staff are vigilant so that people who would not be safe do not go out without support. Some of the garden is being developed for the people who live at the home to grow their own vegetables. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 20 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, 34, 35, 36 People who use this service experience adequate quality outcomes in this area. Staff are well recruited, and most have received basic training, but further training and supervision are needed to make sure that the people who live at 2 Beech Close have their needs fully met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: The manager told us that there are usually four staff on duty in the morning, and four in the afternoon, with additional staff if the residents are all going out. She said there are 12 permanent support workers, 3 of whom are seniors, and 3 bank staff. One staff member said that more staff would help the people who live at the home to develop their daily living skills more rapidly. We recommend that the manager monitor this closely to make sure there are always sufficient staff on duty. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 21 We checked the staff rota and found that on one day only two staff had been on duty. However, the rota was not an accurate record of the staff that had been on duty for the two days we looked at. Staff sign a daily record to show what time they start and finish their shift: this did not match the rota for these days, and the manager said neither were accurate for the day when it looked as though only two staff had been at work. The manager said that six staff have been awarded a National Vocational Qualification (NVQ) in care level 3, and one has an NVQ level 2. We spoke with a new member of staff. He told us that all the checks needed, including a Criminal Records Bureau (CRB) check and references, had been done before he started working at the home. We looked at staff records for two staff and found that all the required checks had been done, other than an explanation for gaps in their employment histories. The manager showed us a form that had been introduced since these staff were employed, which will ensure that gaps in employment are explored for any future recruitment. There was also evidence that TACT monitors staff’s ‘right to work’ in the UK. Training records showed that the majority of staff have had training in moving and handling, medication and first aid. All staff have had safeguarding training and most hold a basic food hygiene certificate. Other courses that staff have been on include risk assessing and person-centred planning. Only four staff have had training in a course which teaches them about managing behaviour without using restraint. Staff must be offered further training in topics related to the needs of the people who live at the home, for example specialist communication skills (such as Makaton if this would be useful), and specific conditions such as autism, diabetes and so on. Records showed that staff have not had adequate training in fire safety. Four people had training in March 2008, several in July 2007, and some not since January 2006. However, the manager said that all staff had had training in fire safety in January 2008. We did not see any evidence of this. All staff must receive some form of fire safety awareness training at least twice in every 12 months. Staff records showed that staff have started to receive supervision. The manager was aware that supervisions have not been done as regularly as they should, and staff will probably not get the recommended six sessions in this twelve months. Staff meetings are held monthly, and minutes taken. A new member of staff we spoke with said that the staff meetings are very useful. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 22 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, 41, 42 People who use this service experience adequate quality outcomes in this area. The management of 2 Beech Close has improved and is beginning to be effective in making sure that the people who live here have a good quality of life and are kept safe. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since 09/06/08 the registered manager of 2 Beech Close, Gladys Quinn, had been seconded to manage 1 Beech Close. The assistant manager, Bob Bradley, had been acting manager at 2 Beech Close. On the day we visited the home Mr Bradley was on holiday so Mrs Quinn assisted us with the inspection. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 23 The home has moved forward since our last inspections. The registered manager completed the AQAA and indicated that she is aware of areas in which the home can continue to improve. The manager told us she has drawn up a plan for quality assurance which covers all aspects of the National Minimum Standards and Regulations, and is based on looking at good outcomes for the people who live at 2 Beech Close. This system has yet to be put fully into operation, so more work is needed in this area to make sure the service is based on the views and aspirations of the people who live here. A representative of the provider visits the home at least once a month, and writes a report of the visit, as they are required to do by Regulation 26 of the Care Homes Regulations 2001. The staff rota was not accurate (see Staffing section of this report). According to the information in the AQAA, all equipment and systems, such as hoists, gas, water and so on have been checked as required by relevant legislation. We saw that all portable appliances were tested in July 2008. The arrangements to protect people in the event of a fire need some improvement to make sure people are kept as safe as possible. Staff training records indicated that staff training was not up to date (see Staffing section of this report). All staff should also be involved in a fire drill at least once a year. On the day of the inspection the record showed the last recorded fire drill took place on 17/06/07. However, following the inspection the home gave us a copy of a record from a new book which showed that fire drills took place in December 2007, February 2008 and June 2008. It is still not clear whether all staff were involved in at least one of the drills. Records of fire alarm tests had been done weekly except there were only two tests done in August. The emergency lighting had been tested at least monthly as required. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 24 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 3 3 X 4 X 5 2 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 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 2 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 3 3 X 2 X 2 X 2 2 X 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 25 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 YA5 Regulation 5 Requirement Information regarding the fees charged to service users, what they cover, and the cost of all facilities and services not covered by fees, must be made clear for each service user. This information must be recorded in the service user contract, and be agreed with each service user (if appropriate) and/or a suitable independent representative for each service user. This requirement is carried forward. Timescale for action 31/10/08 2 YA24 23(2)(d) All parts of the home must be well-maintained so that people have a pleasant place to live. The stained flooring in the bathrooms and kitchens must be cleaned or replaced. This requirement is carried forward. 31/12/08 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 26 3 YA35 18(1)(c) All staff must receive sufficient training so that they can support the people who live at the home as well as possible. Some staff require training in basic health and safety topics, and all staff should receive training in topics related to the specific conditions of the people who live at the home, for example special communication skills (such as Makaton), diabetes, autism and so on. All staff must receive regular supervision so that they are properly supported to do their job well. All staff must receive one session within the timescale, and regularly thereafter. Records required by this regulation must be maintained up to date and accurate. The staff rota must accurately show which staff have been on duty so that it is possible to judge whether there are sufficient staff to meet people’s needs. 31/03/09 4 YA36 18(2) 31/10/08 5 YA41 17 and schedule 4 12/08/08 6 YA42 23(4)(d) All staff must receive fire safety 31/10/08 awareness training as required so that they know how to act in the event of a fire at the home. All staff must have received at least one training session within the 6 months from 01/05/08 to 31/10/08, and as required by the fire authority thereafter. 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 27 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 YA11 Good Practice Recommendations Staff should keep on finding further opportunities for the people who live at 2 Beech Close to continue to develop their daily living skills, and for education and leisure activities, so that people’s lives are made even more fulfilling. The manager should closely monitor the number and effectiveness of the staff on duty to make sure the needs of each person who lives at 2 Beech Close are met. The quality assurance system should continue to be developed so that the home is run in the best interests of the people who live there. 2 YA33 3 YA39 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Regional Office CPC1 Capital Park Fulbourn Cambridge CB21 5XE 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. Extracts may not be used or reproduced without the express permission of CSCI 2 Beech Close DS0000071734.V365015.R01.S.doc Version 5.2 Page 29 - 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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