CARE HOME ADULTS 18-65
Beacon Way (3) 3 Beacon Way Rickmansworth Hertfordshire WD3 7PQ Lead Inspector
Marian Byrne Key Unannounced Inspection 21st June 2007 10:00 Beacon Way (3) DS0000019279.V343762.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 Beacon Way (3) DS0000019279.V343762.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. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Beacon Way (3) Address 3 Beacon Way Rickmansworth Hertfordshire WD3 7PQ 01923 896579 01923 896579 FP beaconway@walsingham.com 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) Walsingham Tammy Louise Finch Care Home 6 Category(ies) of Learning disability (6), Learning disability over registration, with number 65 years of age (6), Physical disability (1) of places Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 7th March 2007 Brief Description of the Service: 3 Beacon Way is a two storey semi detached house that ha been extended and converted to accommodate up to six service users who have a learning disability. The accommodation comprises of a lounge, dinning room, additional small lounge, kitchen, laundry, toilet and an office that provides sleeping facilities for the person sleeping in. On the ground floor there is also a single occupancy bedroom that can support a service user with a physical disablement. There are five bedrooms on the first floor together with a bathroom, shower room and an additional toilet. The home is situated in a sought-after residential area of Mill End on the out skirts of Rickmansworth. There is a small parade of shops and a local pub near by. A local bus service connects with Rickmansworth town centre and a railway station. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector carried out this inspection in the late morning and afternoon. The inspector met and spoke to most of the service users. The Registered Manager was present during the inspection. What the service does well: What has improved since the last inspection? What they could do better:
This was a very positive inspection the only concern is the difficulty in recruiting staff to work on a permanent basis in the home. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 6 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. Beacon Way (3) DS0000019279.V343762.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 Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are fully assessed prior to be offered a permanent place at the home. EVIDENCE: Two service uses assessment were inspected these contained good historical information on the service users and evidence that the home is careful to only offer a home to those prospective service users whose needs and aspirations the home knows it can meet. Service users are facilitated in making decisions on their future in the home. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care plans were excellent; they identify the needs and wishes of the service users facilitating staff to meet needs and aspirations. EVIDENCE: Three care plans were inspected and were found to contain excellent information on how the service users wish to live their lives. They are broken down to day-to-day life including all aspects of how the service users wish to spend their day with clear instructions and guidance for staff. There was evidence that service users had been consulted in the drawing up of the care plans. Service users spoken with confirmed that they are encouraged to have active lifestyles. A one service user has chosen to have a quiet lifestyle this is respected by the home. This service user is active in the life of the home; on the day of the inspection he was taking part in staff interviews. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 10 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The life style of the service users is good. EVIDENCE: The service users choose to have active daily and social lives. On the day of the inspection two service users were out. One attending the local day centre and the other attending a local college. One service user has decided that he no longer wants to attend day centre and the home is actively trying to find a place for a newly admitted service user. The newly admitted service user visits his mother in a residential home in a nearby town twice a week. An outreach worker accompanies him and the outing is extended to include lunch in a garden centre or local café. At the moment the home has special measures in place that prohibits free access to the kitchen area. Service users cannot go to the kitchen unaccompanied, as there are hygiene issues with some of the service users. The registered manager hopes that this will be a short term measure and staff are working with the service users to improve their
Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 11 understanding of food hygiene and personal hygiene. The kitchen contained good supplies of good quality well known brands. Lunch was observed, this was a simple meal of sandwiches, staff and service users ate together. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Personal care is delivered in a manner that respects the service user’s dignity, their physical and emotional health is promoted. Medication was in order. EVIDENCE: The medicines in the home are administered and stored appropriately. Service users spoken with stated that they are happy with the way staff support them. All service users have regular consultations with health care workers and efforts are made to support the service users emotionally. An example of this is one service user has a very elderly mother who is in poor health, the service user is extremely close to his mother, the home have started to prepare him for the time when his mother dies. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There had been no complaints since the last inspection. Service users are protected from abuse. EVIDENCE: The home has a complaints policy that it follows in the event of a complaint. Staff spoken with were aware of how to recognise abuse and how to manage incidents of abuse. The registered manager has made reports to Social Services on issues relating to a service user. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment meets the needs of the service users. EVIDENCE: The home was clean fresh and domestic in decoration and in the furnishings. The registered manager and staff have changed the home hugely since the last inspection. A new kitchen has been installed and the kitchen re-decorated. The sitting room/dining room has had new floor covering fitted and new sofas have been purchased. The hall and stairs have had new carpet and the whole home now looks bright, clean and welcoming. All area of the home, including the toilets and shower rooms, have been attended to this varies from a thorough spring clean to refurbishment of some areas. Some minor details of decoration are still outstanding, the registered manager assured the inspector that these will be attended to in the very near future. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is too reliant on agency staff. EVIDENCE: The home is attempting to recruit permanent staff, this is a priority as the staffing of the home has relied on agency staff for too long. The registered manager is attempting to use the same agency staff where possible to promote continuity for the service users. There were no new staffing files to inspect. The lack of permanent staff impacts on staff training. The registered manager insures that the staff covering the home are aware of the needs of the service users. The permanent staff in the home are dedicated to the welfare of the service users and are trained to meet the needs of their roles as carers. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and the service users are safeguarded. The home is run with the welfare and interests of the service users as paramount. EVIDENCE: The registered manager, who was not present at the last inspection, showed that she was able to manage this home in the best interests of the service users. She is struggling to recruit staff for the home and is balancing this by endeavouring to use the same Agency staff as much as possible, while this is laudable the home must have a core of permanent staff that the service users can rely on and get to know. The health and safety of the service users is protected. Every effort is made to ensure the staff and the registered manager are aware of the needs and wishes of the service users this is done is a variety of ways. Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 18 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 OP27 Regulation Requirement Timescale for action 30/09/07 18(1)(a)&(b) The Registered Manager must ensure that the home is staffed with permanent skilled staff. It is understood that the home is making every effort to recruit staff therefore the timescale for action has been extended. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beacon Way (3) DS0000019279.V343762.R01.S.doc Version 5.2 Page 19 Commission for Social Care Inspection Hertfordshire Area Team 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
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