This inspection was carried out on 24th February 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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOME ADULTS 18-65
5 Beacon Gardens Beacon Street Lichfield Staffordshire WS13 7BQ Lead Inspector
Lorraine Mavengere Unannounced Inspection 24 February 2006 10:00 5 Beacon Gardens DS0000005074.V284746.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 5 Beacon Gardens DS0000005074.V284746.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. 5 Beacon Gardens DS0000005074.V284746.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service 5 Beacon Gardens Address Beacon Street Lichfield Staffordshire WS13 7BQ 01543 264720 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) Mrs Margaret Jean Holton Mr John Edward Holton Mrs Margaret Jean Holton Care Home 2 Category(ies) of Learning disability (2) registration, with number of places 5 Beacon Gardens DS0000005074.V284746.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd August 2005 Brief Description of the Service: 5 Beacon Gardens is a family home registered to provide care for two people with a learning disability.The home is a semi-detached property situated in a quiet cul-de-sac on the outskirts of Lichfield town centre. The cul-de-sac is found off a main road leading into Lichfield, and there is easy access to a large supermarket at the bottom of the road. Access to public transport is also very close by, with regular buses into Lichfield town and all of its amenities.Although registered for two people only one gentleman now lives at the home, and the proprietor has no plans to change this. The service user has been with the family from the age of two and a half years and is now approaching thirty later this year. In that time he has been treated as a family member with the two proprietors acting in loco parentis with the extended family as substitute aunts and uncles. 5 Beacon Gardens DS0000005074.V284746.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced. The service user was present throughout the inspection and was able to contribute significantly to the inspection process. His comments are included in the report. As outlined in previous inspection reports, Beacon Gardens is unlike many registered care homes in that the service user has lived with the family since he was three years old. He is thirty- two now. He is considered as part of the family and goes on family holidays with the proprietors. There has been talk in the past of the service user moving into supported accommodation but this has not materialised as yet. Many of the standards assessed against this home do not fit and are not applicable given the nature of the set up. The service user himself expresses great satisfaction at his way of life. What the service does well: What has improved since the last inspection? What they could do better:
As highlighted in past inspection reports, the home is not very strong on paper work. Given the fact that the service user has been part of the family for nearly thirty years now makes it difficult for the family to formulate written records for someone who they see as nothing less than a family member. It also makes it somewhat difficult to assess some of the standards and to
5 Beacon Gardens DS0000005074.V284746.R01.S.doc Version 5.1 Page 6 measure them against regulations as they just do not fit. Much of the information received was through discussions wit the proprietors and the service user himself, observations and a brief tour of the premises. The one requirement made during the last inspection was for the manager to have a written policy and procedure document for making complaints. After some discussion, the manager suggested that because the service user has always been comfortable raising concerns with family members it was not suitable to introduce the written format at this stage. The manager will accept a complaints procedure from other agencies that may wish to provide him with one. The family set up has always been such that concerns are raised and resolved without any fear. The service user was happy with the format. 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. 5 Beacon Gardens DS0000005074.V284746.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 5 Beacon Gardens DS0000005074.V284746.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): Standards Not Assessed. These standards were assessed and fully met during the last inspection. EVIDENCE: 5 Beacon Gardens DS0000005074.V284746.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, 9 Currently the service user does not have any service user plans or care files in place. Risk is assessed and managed on a daily basis in an informal manner. EVIDENCE: The registered manager confirmed that there have been no care plans recently but she will request one from the social worker. She herself has not carried out any care planning. The reason is that she raised the service users as one of her own. This is since he was three years old. The manager confirmed that all risk is assessed and managed on a daily basis and as the need arises. The manager was able to give examples of when the service user had been vulnerable and how this was handled. The manager and the service user together demonstrated the different risk management strategies that they put in place. These included the service user having a mobile phone as well as him not taking evening employment to avoid him being out in the dark. 5 Beacon Gardens DS0000005074.V284746.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): Standards Not Assessed. These standards were assessed and fully met during the last inspection. EVIDENCE: 5 Beacon Gardens DS0000005074.V284746.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): Standards not Assessed. These standards were assessed and fully met during the last inspection. EVIDENCE: 5 Beacon Gardens DS0000005074.V284746.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): Standards Not Assessed. These standards were fully assessed and met during the last inspection. EVIDENCE: 5 Beacon Gardens DS0000005074.V284746.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): 27, 30 The toilet and bathroom facilities are sufficient to meet service user needs and allow for privacy. The home’s practices allow for the premises to be kept clean, tidy and hygienic. EVIDENCE: A brief tour of the premises showed that the home has a sufficient number of bathrooms and toilets to cater for the needs of the service user. The bathroom and toilet area provide privacy while in use. No bath aids or adaptations are needed for the current service user. Although the home does not have a written infection control policy, the registered manager was able to demonstrate through discussing the home’s cleaning routine that there are no areas of concern. The service user confirmed that he helps out with cleaning up and is in charge of making sure that his own room is kept clean, tidy and hygienic. The home has hand washing facilities sited appropriately. 5 Beacon Gardens DS0000005074.V284746.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): 32, 34, 35 The registered manager demonstrates competence in supporting service users and ensuring that their care needs are met. The home’s recruitment practices safeguard service users. The registered manager has not undertaken any training courses recently but has done many over the years. EVIDENCE: The registered manager has many years experience working with people with learning disabilities. The current service user has been staying with the family for nearly thirty years now and is considered as part of the family. The registered manager does not hold her NVQ4. The living situation is such that the manager demonstrates her abilities to run the home. She stated that she as no immediate plans to do her NVQ4. The home has not recruited any care staff since the service user was admitted to the home nearly thirty years ago. The family have looked after him and not needed to recruit additional staff. It was therefore not possible to assess the home’s recruitment practices other than the people who have been working with the service user for all these years. Both the proprietors have had CRB clearance. 5 Beacon Gardens DS0000005074.V284746.R01.S.doc Version 5.1 Page 15 At the time of inspection there were no training records held at the home. The registered manager confirmed that she had attended different training courses over the years but had not done any recently. Given the family set up she felt that her life experiences and what she has developed during the time that the service user was resident at the home is sufficient. 5 Beacon Gardens DS0000005074.V284746.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 The service user’s opinions and views are sought regularly. The home serves to protect the health, safety and wellbeing of the service user. EVIDENCE: The service user confirmed that the way in which the home is set up allows for him to give his views and opinions freely. He explained that if he has any concerns they are discussed and resolved in a satisfactory manner. It was quite clear from discussions with the registered manager that formalising this would take away from the family set up that they already have. The views and opinions of other professionals are also taken into account on a very informal basis. Like most households, the manager explained that the home is insured and is in a good state of repair. A brief tour of the building showed that there were no health and safety concerns. The house itself together with the gardens is very user friendly and well maintained. 5 Beacon Gardens DS0000005074.V284746.R01.S.doc Version 5.1 Page 17 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 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X x X X 3 X X 3 X 5 Beacon Gardens DS0000005074.V284746.R01.S.doc Version 5.1 Page 18 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. 1. Refer to Standard YA23 Good Practice Recommendations It is recommended that the registered manager obtain a copy of the Local Authoritys policy and guidance on The Vulnerable Adult Procedure. 5 Beacon Gardens DS0000005074.V284746.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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