Inspection on 17/07/06 for 83 Beaconsfield Villas

This inspection was carried out on 17th July 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

83 Beaconsfield Villas 30/10/07

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 83 Beaconsfield Villas Brighton East Sussex BN1 6HF Lead Inspector Jenny Blackwell Key Unannounced Inspection 18 & 22nd August 2006 10:00 th 83 Beaconsfield Villas DS0000066550.V302285.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 83 Beaconsfield Villas DS0000066550.V302285.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. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 83 Beaconsfield Villas Address Brighton East Sussex BN1 6HF 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) 01273 295297 Brighton & Hove City Council William Glassford Demel Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Maximum number of service users to be accommodated is four (4). Three (3) service users must be aged between 18-30 on admission and one (1) service user may be aged between 16-18 on admission. Service users with a learning disability only to be accommodated. Date of last inspection NONE Brief Description of the Service: The home was registered with the Care Standards Commission in February 2006 to provide 24 hour residential care for up to 4 young learning disabled people. The home was initially set up to provide accommodation for people leaving children’s services in Brighton and Hove. The Provider organisation is Brighton and Hove City Council. The building is a detached four storey converted period building in a residential setting in Brighton. The building was converted from a day service to a residential building in 2005 and know provides accommodation for one person in a flat and up to three others in the main house. The bedrooms are singles with appropriate communal space. The home is domestic in scale and has a large garden that provides a safe and pleasant space for the people to spend time in. The fee information for 83 Beaconsfield Villas is yet to be passed to the Commission. As the home is run by Brighton and Hove City Council specific set fee amount had not been calculated. This information will be required for the next published report. More detailed information about the services provided at 83 Beaconsfield Villas can be found in the home’s Statement of Purpose and Service User Guide – copies of these documents can be obtained directly from the Provider. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The reader should be aware that the Care Standards Act 2000 and Care Homes Regulations 2001, uses the term ‘service user’ to describe those living in care home settings. For the purpose of this report, those living at 83 Beaconsfield Villas are referred to as “people” or “person”. People working at the home will be referred to as “staff” or by their job title. This report reflects a key inspection based on the collation of information received since the last inspection, feedback from a visiting professional and an unannounced site visit which lasted a total of ten hours on Friday 18th August and an announced visit on Tuesday 22nd August 2006. This was the first inspection to the home since the registration of the home in February 2006. The site visits included a tour of the premises and an examination of medication, care and staffing records. Throughout the inspection process, the Inspector spent time with three people, one person individually and observed the way the people were supported in communal areas. A telephone conversation was held with two visiting professionals. Written feedback was received from two relatives. Time was spent briefly with a visiting relative. The manager was present during the inspection. The deputy manager was met with during the site visit. In addition, two staff were spoken to individually and two others together. What the service does well: The inspection process has identified the home as operating good in most areas and adequate in two. The feedback form relatives and visiting professionals all stated how well the management and staff had worked during the transition period between children’s and adult services. Staff worked along side their children’s services colleagues with two of the people for several months before their move to Beaconsfield Villas. The individual plans were drawn up from the knowledge they had gained whilst working with the people to ensure that the important daily routines for people were continued at Beaconsfield. The staff team work with situations with the people during the day that can challenge them. They have work well with other professionals to ensure that they have clear guidelines to support the people appropriately. The staff team although a new group displayed a good understanding of providing support to the people that was consistent. Written guidelines 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 6 supporting this approach were detailed and evidence was gained during the inspection that all staff had been training in working to the guidelines. Staff were positive about the work they undertook at the home and felt united as a team. They expressed praise for the management of the home finding them supportive and approachable. The manager had ensured that the home operated to the National Minimum Standards and had met the majority of the key standards within the home first year of operation. 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. 83 Beaconsfield Villas DS0000066550.V302285.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 83 Beaconsfield Villas DS0000066550.V302285.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Assessments had taken place to review the individual’s needs and aspirations, however the review records had not been forwarded to the people and staff. EVIDENCE: Two of the people who have moved to the home are new to adult services and all three had a community care assessment before moving in. All three of the assessments were viewed during the visit to the home. The assessments were carried out by a social worker form Brighton and Hove City Council who are the placing authority for the people. The assessments were comprehensive identifying the support needs for each individual. The assessment looked at the level of staffing people would need to support them with activities inside and outside of the home. The people’s likes and dislikes were identified and specific information about the level of risk people would be experiencing during activities was identified. The assessment record stipulated a timescale for review of the assessment which was six weeks after the beginning of each persons placement at the home and then annually. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 9 The manager was asked about the review schedule. He said that the six week reviews had taken place and was conducted by a reviewing officer from the placing authority, however the report from the review had not been received by the home. The importance of having the initial placements reviewed and reported on was discussed with the manager. He said he would follow up the review document to ensure the placement’s of the people at the home was assessed as still being suitable. The organisation has a policy of reviewing the daily living aspects of the people’s lives. This is done every six months where the staff work with the person to assess whether their every day aspirations are being met. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 10 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 this service. The people’s needs are covered in their plans including risk assessment. People were seen to make choices throughout the inspection. The staff supported their decision-making. EVIDENCE: The staff at the home have been using the care planning system since the home opened. The staff spoken to on the visits had a good understanding of the plans, and two staff made reference to information in the plans when discussing the support needs of the individuals. The plans for each person were viewed during the visits. Each plan contained “pen pictures” of the person that set out their interest, and family contact details. Information was held in the plans about peoples weekly schedules and what activities they attended. The information was index in the same way for each person and the information was easy to find. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 11 The organisations forms were being used in each plan. For example a form for when a person went missing was filled in for each person, it included information about the persons appearance and the homes and next of kin contact details. The staff have been working with the individuals to reduce behaviours that can sometimes be a challenge for staff and others. The staff had involved the person and worked in partnership with other professionals to develop specific approaches to types of support. These have been recorded in detail as guidelines and all staff are expected to work to them. They are worked through in staff meetings and supervisions; the staff spoken to on the visits confirmed this. One staff member who was a relief worker was asked about how he would work with one of the people. He described the routines and approaches he would use. These methods were checked against the persons guidelines in their plan and found to be accurate. The staff team were working with one of the people in a particular way and had sought the advice of a speech and language therapist. The guidelines were detailed and ensured the staff supporting the person were fully informed. The staff team and manager had been trained by the speech and language therapist and had continued to work with her for a number of weeks. The three people are encouraged to make choices and decisions around the home. This was observed during the visit as one person was seen to be offered choices by the staff supporting him. These included choices around food, clothing and how he wished to spend his day. Another person had some choice about what he wanted to do day although due to his support needs his day was far more structured. The other person arranges his life himself with support and guidance from staff. Time was spent with him where he said what he did during the day and talked about his interest and his family. The staff had worked well to provide a framework of choice and decision making for the people as this often caused difficulty for the individuals. Staff were seen to act sensitively towards the people if the were having difficulty making choices or understanding their options. Staff were seen to use objects and signs to help the people understand their choices, what they were about to do or were they were going. Comprehensive risk assessments had been undertaken for each person. The areas covered included access to parts of the home, travelling out in the community, and for staff to safely work with people on a 1:1 basis. The staff were aware of when it was important to review and update risk assessments. Evidence was seen of where assessments had been updated in one persons plan. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff ensured that the people took part in meaningful appropriate activities both at home and in their local community. The people were able to continue their family relationships. The rights of the people were respected and the home and provider organisation were developing their understanding of protecting the people’s privacy. Meals were prepared well and appeared to be a balanced diet. EVIDENCE: The staff team supported each person to engage in activities in and out side of the home. The support plans had information about activities each person likes to take part in. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 13 One person living at the home has support during weekdays from an education team. He works with regular staff from the team and they assist him with developing skills for life. On the day of the visit one person was out home for a pub lunch and another person had been out for a walk. The third person arranges what he was doing for the day himself and arranged support from the staff when he needed it, he has recently been offered a place at college. As part of the monthly monitoring visits to the home conducted by a representative of the provider (Brighton and Hove City Council) called the Care Standards Officer, the variety and regularity of activities offered to the people are looked at. This is recorded in a report and passed to the manager and the Commission. During the visits all three people were out and about during the day. The staff were well organised in supporting the people to attend their activities. One persons weekly schedule was viewed. He went swimming and cycling regularly and went to work experience. Household tasks were also planned like food shopping and preparation of meals. Lists of interest and favourite places to go were in all of the people’s plans. Going to the cinema, eating out at restaurants and going to car boot sales were some of the interest indicated. One person was asked if he liked the interests that were listed for him, he said he did and showed his collection of films and music. Another person spent time in the lounge and choose a video to watch of his friends and family. The staff talked with him whilst the video was on and made reference to the people he knew. He used a variety of communication methods to engage in a conversation with the staff about the video. Later he went to his room to play a keyboard instrument. All the people were actively engaged in their local community by using shops and leisure facilities. They all have regular contact with family and one person has a shared care arrangements were he spends time at his family home. A brief time was spent with a parent who visited the home. She said she had a good relationship with the staff at the home and felt that her son’s transition from children’s services was handled particularly well. During time in the home it was noted that one person was having a health care issue monitored by a listening devise. This devise was intrusive as it meant that anyone in a communal area could listen in to him in his bedroom. A discussion was held with the manager and the senior line manager of the home on the second visit. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 14 The manager had said that the issue had been raised with in the staff team although they had not come to any conclusions. This practice was also recorded as a restrictive practice under Brighton and Hove City Council Restrictive Practices policy. The manager was seeking advice from a health care specialist to obtain more appropriate and specific monitoring devices. It is required that the manager ensures that the people’s right to privacy is protected. The meals at the home are prepared by the staff with some assistance and involvement from the people. The manager submitted two weeks menus to the Commission as part of the pre inspection questionnaire. The manager stated the menu was written from known preferences of the individuals and is adapted to ensure that it was a balanced menu and nutritious. A meal was being prepared by the staff on one of the days of the visit. It appeared well prepared and the staff members demonstrated some knowledge of the peoples likes and dislikes when asked. 83 Beaconsfield Villas DS0000066550.V302285.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 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 service. The staff had ensured that the people’s preferred methods of personal support were recorded and adhered to. Each person’s physical and emotional health needs were met. The staff understood their roles in administering medication and the policies and procedures protect the people when dealing with their medications. EVIDENCE: Each person’s preferences about how they liked to receive personal support were recorded in their plans. Daily morning and evening routines were recorded for each person. The information was held securely in the homes office. The staff were seen to handle information about the people sensitively and, when asked, the staff could talk through the personal support routines of each person. Each person is registered with a G.P and attends community-based appointments for dentists and opticians. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 16 Health care monitoring for each person is recorded in the daily records and is looked at formally in Brighton and Hove six monthly review process. The manager said that the staff worked closely with G.P’s, psychiatrist and community nurses who support the current group of people. A speech and language therapist was spoken to by telephone about her involvement with the home. She said she was working with two people at the home and worked closely with the staff to support the individuals. She described the staff team as an excellent team and very committed to following the guidance she had set out to help the people she was working with. The medication system was checked with the manager. The manager displayed a good level of understanding about the medication the people were taking and the functions of the medicines. The administration of medication was recorded appropriately and information was kept in the medication file about each drug the people took. The manager had provided information of the staff that had been trained in the pre inspection questionnaire. 16 out of the 18 staff have been trained and were responsible for administering medication. It was noted that one liquid form of medication might have been used although the drug had not been signed for. As the medication was a type that could be misused the staff double signed the amount received by the home and when they returned any unused medication. It was recommended the manager take regular stock check of this medication. 83 Beaconsfield Villas DS0000066550.V302285.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 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 this service. The people who live at the home relied on others to raise complaints on their behalf, the complaints system is suitable to support their complaints and concerns. The people are generally protected from abuse, further work was needed in handling peoples monies. Staff have been suitably trained in detecting and reporting abuse. EVIDENCE: The organisation has a complaints leaflet that has been designed to be more accessible to some people by using pictorial information. The current group of people living at the home would need varying levels of support to make a complaint. The manager said the home would rely on relatives, staff or other people to make a complaint on their behalf. The Care Standards Officer checks complaints during the monthly visits. A parent who responded on behalf of her relative in the service users survey said she would approach the manager initially if she had had a complaint although she ticked “no” to the question do you know how to make a complaint. As the home is a new service it would be advisable for the manager to check if representatives have all the information necessary to make a complaint. Another relative stated they did know how to make a complaint on the survey. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 18 The staff receive mandatory training in Protection of Vulnerable Adults (POVA) The manager provided information of the staff that have to date attended and have been nominated to do training in POVA. Three staff, a senior staff and a relief member of staff were spoken during the two visits about the training they received in protection of vulnerable adults. One person had attended the training and the two other newer staff had been nominated to attend. The senior and the relief staff had not attended the course, although the senior had undertaken the N.V.Q 4 that comprehensively covers POVA issues. Evidence was seen that the staff work to procedures that protect people from abuse. The home has procedures to protect the handling of the individual’s monies. However during a check of two peoples monies some errors in recording were found. Some small amounts of monies had not been accounted for in the book where all transactions were accounted for. A discussion was held with the manager about ways to improve the system; he was keen to improve the system and discussed systems that other homes were using. It is required that the people’s monies are appropriately managed and recorded. A discussion was held with the manager and the senior line manager for the home about the work the staff undertake when working 1:1 with one person. The staff have developed specific working practices with support and guidance from Brighton and Hove’s Behavioural Support Team and psychiatrist input. The team have worked hard at ensuring the person has settled into the home and that he received a smooth transition from children’s services. During the inspection and previously from information passed to the Commission from the home, it was noted that the person was engaging with staff in a physical manner that left staff with minor injuries. The discussion with the manager and senior line manager focused on the necessity to reduce these incidences further to protect the staff and the person from harm. The manager stated that he would in conjunction with the line manager introduce further strategies that would attempt to reduce the level of incidences. The Commission will monitor the situation until the next inspection. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 19 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The converted building provided people with a homely and comfortable environment and generally safe. The home was clean and staff had been trained in infection control methods. EVIDENCE: The home is a converted period building divided into two living spaces. A one bedroom, self-contained flat and a group home with three single bedrooms. The building has been converted to support the needs of the people currently living at the home. The manager had reported there had been some issues with the conversation and some problems had taken a while for the contractors to put right. He was now generally happy with the condition of the building. A tour of the premises took place during the two visits. The main building had three single bedrooms, two lounges and kitchen/dining room, a bathroom and separate toilet. One of the bedrooms was en-suite. Currently two people live in the main house. The office was on the ground floor of the building and the manager’s office and staff sleeping in room was on the lower ground floor. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 20 The communal areas in the home were well presented and personalised with photos of the people and their families and friends. The lounges had comfortable furniture and items of interest for the two people including TV’s, music systems and games. It was noted in one lounge that the door closure had made a hole in the wall where the door opened. This was pointed out to the manager who said he would notify the contractors. The kitchen/diner is a large space and accessible to all the people in the main house. The staff had taken steps to help the people use the kitchen by having pictures on the doors of the cupboards showing what was in them. The kitchen was clean and well presented. The extraction facility in the kitchen appeared inadequate for the type of oven and hob. This was discussed with the manager who said a new hob extractor hood had been requested. The bedrooms were viewed for both people. One person had his photo on his bedroom door. Out side his bedroom door the landing light flickered, the manager said he would ensure that he would get it fixed. Both bedrooms were large and had many personal items. One person had a double bed and a large beanbag in his room and the other person bedroom was well set out and again photo prompts were used on his set of draws to help him recognise what clothing was in each draw. It was noted that windows in one persons bedroom were not restricted meaning that the window could open up fully. It was required the manager ensures all windows that pose a safety or security risk are restricted. The ensuite bathroom was clean and well presented. There were no personal items on display in the bathroom. The bathroom on the second floor would be shared between two people with the fourth person moving into the home. The room is large with bath and shower facilities. The third bedroom in the home is smaller than the other two and a discussion was held with the manager about the need to ensure it would meet the needs of any new person moving to the home. Time was spent with the person in his one bedroom flat. He said the flat was set up to how he liked it and he would change things around if he wanted to. The flat had a kitchen/dining room, a lounge bathroom and bedroom. The flat was spacious and homely; the person evidently set it up with as many of his personal belongings were around. He said he prepares his meals with support from staff and also takes care of the flat himself with support. The staff space was well organised and the office was accessible to the people. The office was well equipped and records were stored securely. The office door did not have a fire door closure attached although the door appeared to be a fire door. It was required the manager review all the doors in the home to ensure those that are designated as fire doors have appropriate closures attached. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The services recruitment policies and procedures protected the people who used the service. The evidence provided during the inspection indicates staff were appropriately trained to meet the needs of the people. EVIDENCE: Relatives of two people filled in two surveys and returned them to the Commission. They described the staff as “very good and considerate” and the manager as “excellent”. Another relative said that everyone bends over backwards to understand if and why her relative is ever unhappy and that he has never been more content. The recruitment records of the staff were checked for four staff members. The records were appropriately stored. Two of the staff members had application forms in their files and all three people had written references from previous employers. Criminal Records Bureau checks had been carried out for all of the staff and records of 1:1 supervision with senior managers were recorded for three of the staff. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 22 The organisation had robust recruitment policies and procedures based on protecting vulnerable adults. A staff member spoken to who had recently joined the staff team spoke about his recruitment to the organisation and to the home. He confirmed that references and checks were taken up before he was able to start working in the home. Two staff were spoken to together during on visit. They were asked about their roles in the home. They talked about the routines of the individuals they supported and the joint working with the education team. They were asked about their training and induction to the home. One staff said that she was currently on in-house induction and had attended some training to date. She had not started the formal induction process as she was informed that she needed to attend Brighton and Hove’s introduction to Learning Disability. This had caused some delay in her starting the induction course; it is recommended that the manager ensure that the induction programme is compatible with mandatory induction. The staff team spent time during the transition period at the children’s service getting to know two of the people. They worked alongside the children’s staff team to build good relationships with the two people. A community health care professional was spoken to by telephone about the staff team. He described the team as open to new ideas and different ways of working and went on to describe them as “excellent”. He particularly praised some work the team had done with one person around a recent bereavement he had experienced. They had developed a booklet that was used with him to help communicated aspects of going through a bereavement. The staff were asked about the training they had since working at the home. A speech and language therapist had recently trained them in particular communication techniques to use with one person. One staff had undertaken training in adult protection. A relief member of staff said he had had training in administering medication. The manager provided information in the pre inspection questionnaire that showed the staff were accessing training needed to support the individuals. The staff spoken to during the visits confirmed that they had attended the training. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 23 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): 37,39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people who live at the home benefited form the service being well run with clear lines of accountability. Self-monitoring in the home is being developed but is not in place currently. The home ensures it promotes the health safety and welfare of the people and staff in general with some additional attention needed to be paid to having particular documents in place and physical incidences in the home. EVIDENCE: The manager has been running the service since the beginning start of the service he is supported by two senior care officers post although one is vacant. The staff spoken said they found the manager and seniors approachable. The one person spoken to directly during the visits knew who the manager was and said he could talk to him if he had any problems. Both the visiting health care professionals and the relative gave feedback about the manager. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 24 They said that the manager was approachable, flexible and had fresh ideas in working and valued the people and staff. The manager is currently doing the N.V.Q 4 and the Registered manager’s award. The home is well run and one staff talked about getting good support from the senior line manager to the home. The manager discussed a quality assurance programme he had developed which he hoped to develop further in house. Surveys had been sent out to the relatives by the home to ascertain their views on the home. Brighton and Hove had developed some tools to check the quality in their services including information about incidents and accidents, staffing issues such as sickness and supervision, compliance with health and safety checks and the peoples records like their individual plans. This information needed to be put together to produce a report to evidence that the home self monitors the quality of the service. As the home has only been registered in ’06 the development of the quality assurance system will be monitored during the next inspection schedule. The staff conduct weekly and monthly health and safety checks of the premises. This includes weekly fire detection system checks and hot water checks. The fire file was looked at. It was found that the systems had been checked and outcome recorded in line with the services procedures. The section in the file for the fire risk assessment for the home was not in place. It was required the home produce a fire risk assessment for all areas of the home. Other risk assessment for the home was seen including illnesses, control of hazardous substances and risk of injury. Accidents and incidents file was view and found to be recorded appropriately. The manager ensured that incidents were reported to the Commission when required under the Care Standards Act 2000. As stated earlier a significant amount of incidents had been reported which involved one person being physically engaged with staff resulting in minor injuries to staff. This situation will need to be closely monitored by staff, managers and the placing authority (Brighton and Hove) to ensure everyone’s health and safety is protected. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 25 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 2 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO 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. 2. 3. Standard YA16 YA23 YA24 Regulation 12(4)(a) Requirement Timescale for action 22/08/06 22/08/06 30/12/06 4. YA24 YA42 5. YA42 It is required that the manager ensures that the peoples right to privacy is protected. 13(6) It is required that the people’s monies are appropriately managed and recorded. 13(4)(a) It was required the manager ensures all windows that pose a safety or security risk are restricted. 23(4)(C)(i) It was required the manager review all the doors in the home to ensure those that are designated fire doors have appropriate closures attached. 23(4)(a) It was required the home produce a fire risk assessment for all areas of the home. 30/12/06 30/12/06 83 Beaconsfield Villas DS0000066550.V302285.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. 2. Refer to Standard YA20 YA35 Good Practice Recommendations It was recommended the manager take regular stock check of particular medication. It is recommended that the manager ensure that the induction programme is compatible with national mandatory induction. 83 Beaconsfield Villas DS0000066550.V302285.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection East Sussex Area Office Ivy House 3 Ivy Terrace Eastbourne East Sussex BN21 4QT 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 83 Beaconsfield Villas DS0000066550.V302285.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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!