Inspection on 16/08/07 for Beaconhurst

This inspection was carried out on 16th August 2007.

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

Other inspections for this house

Beaconhurst 13/12/06

Beaconhurst 26/06/06

Beaconhurst 02/12/05

Beaconhurst 17/06/05

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Beaconhurst 1 Gorge Road Sedgley West Midlands DY3 1LF Lead Inspector Jayne Fisher Key Unannounced Inspection 16th August 2007 09:45 Beaconhurst DS0000062601.V345867.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 Beaconhurst DS0000062601.V345867.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. Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaconhurst Address 1 Gorge Road Sedgley West Midlands DY3 1LF 01902 882575 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) Minster Pathways Limited Mrs Sandra Anne Bebb Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 13th December 2006 Brief Description of the Service: Beaconhurst House is an independent sector Care Home that was registered in the latter half of 2005. The maximum number of service users it can provide care to is three. The service user group is younger adults with learning disability and autism. The home is a converted private residential property located near to Sedgley. It is within easy travelling distance of the local town, community facilities and a public transport network. Accommodation is provided over two levels. On the ground floor is a communal kitchen and bathroom. There are three spacious bedrooms on the ground and first floor each with a separate lounge area. One bedroom has an ensuite. There is a further second bathroom on the first floor. There is a large secure garden area to the front and rear of the property, and off road parking facilities are available for visitors. Information regarding fee levels was provided by the manager on 16 August 2007 which are around £2,300 - £2,900 per week. This does not include extra services such as private health and dental care, hairdressing, dry cleaning and chiropody. These are all available at extra cost to the residents. A statement of purpose and service user guide are available to inform residents of their entitlements including how to access a copy of the inspection report. Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place between 09.45 a.m. and 6.45 p.m. and was undertaken by one inspector with the home being given no prior notice. We met two of the three residents who live at the home, the third resident chose not to meet us. Formal interviews were not appropriate so we relied upon brief chats and observations of body language and interactions with staff. We spoke with the registered manager, deputy manager and three members of staff. A questionnaire was received from a relative. We looked around the home, examined records and observed care practice. We also looked at all of the information that we have received about this home since it was last inspected. What the service does well: Our inspection visit found that this care home continues to improve and provides residents with a safe, consistent and calm, well organised environment. Staff demonstrated that they understand how residents communicate using verbal and non verbal cues; they responded well to their emotions and needs through out our visit. Care planning is good and residents are able to express their wishes and aspirations, which they are helped to achieve by staff. Management and staff are always looking to find new ways of engaging residents in activities they may enjoy. They are supported to make choices at their own pace. They have lots of outings into the community and have been on holiday. Staff are quick to identify if a resident is unhappy and will try to find out the cause. Management and staff work closely with other professionals in order to meet residents’ health care needs. The relative who completed the comment card was very happy with the service provided by staff saying “every effort is made in making life comfortable and fulfilling”. There are male and female staff employed so that residents can have a choice about who they wish to support them. Residents’ bedrooms and living areas have been decorated and furnished with soothing colour schemes and lighting to make them feel comfortable and secure. Staff showed a caring and sensitive approach towards their roles and we saw lots of positive interactions between residents their key workers. Staff are supported by a competent, dedicated and skilled manager. The manager runs the home in the best interests of the residents including providing a safe but at the same time stimulating environment which encourages independence and opportunities for personal development. Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 6 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. Beaconhurst DS0000062601.V345867.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 Beaconhurst DS0000062601.V345867.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): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents have the information they need to make an informed choice about whether or not they want to live in the home. Before they are admitted to the home new residents are fully assessed in order so that they can be assured that the care service can meet their needs and wishes. EVIDENCE: There is a pictorial service user guide for residents to read and find out what services they are entitled to. They each have a folder which contain important policies and procedures which have been reproduced in pictorial formats. We looked at the statement of purpose which is also very informative and comprehensive. There are only a couple of areas that need expansion which we discussed with the manager. For example, there are details regarding the registered provider but these do not include the experience or relevant qualifications. There are measurements of residents’ bedrooms but ideally there should also be measurements of other areas to which residents have access such as their lounges, bathrooms and the kitchen. The manager agreed to include this information. Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 9 There have been no new residents admitted since our last inspection as the home is fully occupied. We saw copies of assessments undertaken at the time the last resident was admitted in September 2006 and which are held on his file. We met the resident and he looked at ease in his surroundings having developed a good rapport with his support staff and manager. We saw letters on his file from psychiatrists and psychologists which confirmed that he was settled at the home and reported on the progress he was making since coming to Beaconhurst. This demonstrates the effectiveness of the assessment process undertaken by management and staff. We saw that residents had contracts in their files with details of their fees. Beaconhurst DS0000062601.V345867.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. 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. Care plans are comprehensive tools used by staff to assist them in providing support to residents. There is a person centred approach to enable residents to make their choices known about their lifestyles and aspirations. Residents are enabled to take risks as part of every day living and this is managed in a constructive and supportive manner. EVIDENCE: We looked at all residents’ care plans and interviewed staff to gauge whether or not they knew the contents. It was pleasing to find that they had signed the care plans and that they were following them and updating these when residents’ needs changed. For example, one resident had initially needed increased support to access the garden area but this had changed and so had his habits when he was in the garden. We saw that care plans covered a wide range of topics and included long and short term goals. Subjects included motivation, morning and night time routines, absconding, independent living skills, personal care, relationships, health care and activities. Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 11 Care plans are very comprehensive with detailed guidelines for staff to follow when supporting residents.. They are reviewed by staff at least every six months however we did suggest to the manager that there needs to be system in place to evidence that residents, their relatives and significant professionals are invited to attend and participate in these reviews, which she agreed to do. We also suggested to the manager that a specific care plan could be developed regarding how the effects of autism experienced by residents impacts upon their daily lives. The manager agreed that this was a good idea. Whilst there is a comprehensive assessment tool for new residents, we also recommended that existing residents’ needs are reviewed from time to time using an assessment tool to help measure any changes in needs and to help ensuring care plans are reflective of people’s needs. Each resident has a person centred plan in place which is pictorial and includes identifying a circle of friends as well as residents’ hopes and dreams. It was reassuring to find that these were translated into formal care plans and were being achieved. There are care plans in place regarding how residents’ communicate and we observed staff communicating effectively with people throughout our visit. One member of staff told us “we try to understand them and communicate, we use pictures and I think X has made good progress”. We saw details of advocacy services displayed. Residents are supported to manage their finances and there were care plans in place regarding how this is carried out by staff. We saw a range of risk assessments in place for residents. They were comprehensive and clear. For example, there were control measures identified to help manage such risks with regard to eating and drinking, swimming, challenging behaviour, travel on the minibus and access into the community as well as independent living tasks. Interviews with the manager and our observations through the day confirmed that residents are supported to take risks as part of an independent lifestyle for example one resident is supported to make his own drinks. Beaconhurst DS0000062601.V345867.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. 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. Residents are able to enjoy a full and stimulating lifestyle which is structured according to their needs, but at the same times allows for flexibility. Contact with relatives is actively promoted. Residents can choose when and what they would like to eat. They are provided with a healthy and varied diet. EVIDENCE: At present residents do not attend any college courses but discussions with management confirms that they are hoping to encourage residents to do so when the new term starts, but that this is very much based upon residents’ own decisions. Staff clearly understand that choices with regard to daily activities can be daunting for residents so they are allowed to make decisions at their own pace. For example during our visit two residents chose to stay in bed and got up at a Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 13 time of their own choosing. They both then went out separately into the community assisted by staff to visit a destination of their own choice. One resident remained at home during the day participating in his favourite activity; staff did not exert any pressure in trying to get him to try something different. There are detailed activity planners in place for each resident which are changed weekly. These identify a range of varied and stimulating activities. However, despite having a range of recording sheets regarding residents’ daily activities, these do not correlate with the activity planner. Staff are not recording whether or not the initially activity planned was offered, and refused, or why another was chosen. For example, on one day, the activity planner indicated that the resident could spend the day cleaning the minibus, going shopping, going strawberry picking, bowling and going to a disco. The daily diary recording system for the corresponding day stated that the resident had got up late, went outside in the garden, took his medication and slept well. We discussed this with the manager who agreed and said that the recording systems did not reflect the level of supported offered to residents during the day time regarding their activities. We saw from our observations and interviews with staff that residents regularly go out into the community. There are planned staff on duty each day to undertake specific hours allocated to social inclusion. We looked at records and saw that families visit and staff assist residents to keep in contact according to their wishes and preferences. A comment card we received from one relative stated “we have very close communication with the staff”. The relative also stated that they felt the care service respected their family member’s individual privacy and dignity. We spoke with staff and saw that they had a good understanding of respecting residents’ rights. For example one resident chose to participate in a particular favourite activity for the whole day and staff were overhead talking to him in a calming manner and staying in close proximity so that he could see them but they did not invade his space. Staff were seen knocking on residents’ bedroom doors before entering and appropriate privacy locks have been fitted. We did note that some entries made by staff into residents’ records could be deemed as disrespectful and inappropriate in their tone and terminology. The manager stated that this was a language issue and said that she is looking to arrange training in report writing. We looked at menus and saw that these contained two choices for each meal. On the day of our visit staff were preparing a roast pork dinner for residents’ lunch the second option was a jacket potato with cheese. There were nutritional care plans in place and details of people’s preferred likes and dislikes. One resident is receiving nutritional supplements which are fully Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 14 recorded on the appropriate medication chart. There are detailed nutritional screening tools in place. In the kitchen there is a notice board which displays the daily choices available for residents in pictorial format. There is also a pictorial/picture menu to enable residents with choice making. We looked at records of individual residents’ daily food choices and saw that they had chosen differing options for breakfast and tea although for the main meal of the day they had usually chosen the same meal. Staff explained that this was because all residents’ liked to have traditional roast dinners most of the time. We looking at meals during a one week period and found these to be healthy and varied, for example, roast pork, roast beef, fish, shepherds pie and pizza. Beaconhurst DS0000062601.V345867.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal support in the way they prefer and require and their health needs are well met. There are systems in place for residents to safely receive their medication. EVIDENCE: There are detailed care plans in place regarding how residents like to be supported with their personal care. A relative who completed survey said that they felt the care service mets the health care needs of their family member. They also stated that the staff responded well to the different needs of the individual. There are female and male staff so that residents have a choice about who they wish to support them. We saw detailed health care records. Each resident has a separate health care folder with a range of care plans in place including how to help the resident if they feel unwell. We case tracked a resident’s health care appointments and saw that he had seen his doctor on a number of occasions when staff were concerned about his health, he had received blood tests, been to the chiropodist and had an eye test and visited the dentist. There was evidence of Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 16 regular contact with psychiatrists and psychologists. The dietician had also been contact as staff had been concerned about weight loss. There was a detailed health check booklet but the health action plan had yet to be fully completed. We suggested to the manager help could be sought from the community learning disability nurse and primary care team for completion of this tool or the ‘Priority for Health Screening Tool’ which is a specific assessment booklet established by the local community learning disability and primary care team. On the day of our inspection a dentist visited to see one of the residents however they were asked to return by staff as the resident had refused to be examined. We saw staff administering medication and observed that correct procedures were followed. We interviewed a senior support worker and he showed us the arrangements in place for medication. There are good systems in place for the ordering, receipt, key holding and storage of medication. Medication administration record (MAR) sheets were found to be correct with no gaps. We did suggest that any ‘as directed’ dosages on the computerized MAR sheets are clarified with the prescriber with more detailed records entered onto the MAR sheet mainly with regard to the administration of creams. It was also recommended that the temperature of the drugs cupboard is checked from time to time to see that this does not exceed 25 oC. There are detailed guidelines in place regarding the administration of ‘as and when’ required (PRN) medication. Examination of MAR sheets revealed that this is infrequently administered which is commendable. We saw that the maximum dosage in twenty four hours still needed to be added to the guidelines however the manager had already made contact with the psychiatrist to obtain this information. We suggested that the maximum consecutive days that medication is administered before medical advice is sought, is also added. Beaconhurst DS0000062601.V345867.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a comprehensive complaints system which ensures that people’s views are listened to and acted upon. Whilst there are procedures in place to safeguard residents from abuse, slight improvements are needed with regard to financial systems to ensure that these are robust and offer suitable protection to residents. EVIDENCE: There has been one complaint received since our last inspection. We looked at records and saw that details had been fully recorded and appropriate action had been taken by a senior manager to resolve the issue which had been highlighted by a neighbour. There is a comprehensive complaints procedures and this has been reproduced in a pictorial format for residents. The relative who completed a survey stated that they felt the care service always responded appropriately if they raised any concerns. We interviewed two staff members who gave appropriate responses to how they would deal with a complaint. One staff member told us “if the family wanted to complain we would offer them to talk to the manager, we have got policies and procedures, we can’t avoid”. A second member of staff stated that if they received a complaint from a resident they would “I would listen and take it seriously and report it to the manager”. There have been no allegations made regarding vulnerable adult abuse at Beaconhurst since our last visit. There was a copy of the Local Authority safeguarding and protecting vulnerable adults procedures available in the Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 18 manager’s office. Five of the twelve support staff employed have received training in vulnerable adult abuse. We interviewed staff who gave good responses as to how they would deal with any potential incidents of abuse. For example one staff member said “I would report it to the manager, it’s not easy but yes I would”. There were detailed behavioural support guidelines in place and staff told us that during the last six months the incidents of challenging behaviour exhibited by residents had decreased which we confirmed when we checked records. All staff who were interviewed gave clear and consistent responses as to how they would manage any potential incidents of challenging behaviour which were consistent with support plans. They identified the triggers and de-escalation strategies employed which were consistent with the low arousal techniques identified in care plans and advocated by the manager who is an accredited trainer in Strategies for Crisis Intervention (SKIP). Two of the three residents living at the home have their finances managed by their families or the Local Authority. The third resident’s finances are managed by the provider who acts as appointee. Whilst there are detailed records of the monies received by the manager on behalf of this person, the manager told us that money is then transferred into a central account operated by the provider for service users who do not hold bank accounts. The manager was unclear as to whether this was an interest bearing account and could therefore not provide any details as to what if any, interest had been accrued by the resident. Ideally, registered persons should not act as agents and if this is unavoidable there must be robust and transparent procedures in place and in line with guidance issued by the Commission regarding corporate appointees. We saw that money is transferred from the provider to the resident and there are detailed records kept which balanced when we checked with the money held on the premises on behalf of the resident. There are receipts for purchases and two signatures from staff members for any transactions. We saw that residents pay a contribution towards fuel used by the home’s vehicle. The manager explained that there is a central budget on a weekly basis but that if this is exceeded then residents pay the extra money towards fuel costs. There was no evidence that residents had consented to this system and there was no mention in their contracts or service user guide. Similarly on occasion residents pay for their own ‘take-away’ meals if they choose to have more than one per week. As we discussed with the manager this needs to be discussed with the resident and within a multi-disciplinary team including Local Authority commissioners. Outcomes should be recorded in the individual residents’ contracts and service user guide. Beaconhurst DS0000062601.V345867.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home offers a low arousal environment suited to people with autism, some areas are in need of redecoration and refurbishment. Infection control practice needs improvement in order to offer greater protection to residents from cross infection. EVIDENCE: We toured the building and visited two residents’ bedrooms. It was pleasing to see that there was a maintenance person present who was redecorating a resident’s bedroom. The manager told us that a refurbishment programme is underway but that progress has been difficult because the main priority has been to minimize disruption to residents’ lives. The manager said that there are plans to refurbish the kitchen and to replace carpets. We saw that some areas could benefit from redecoration. For example, the communal hallway had stained and worn wallpaper, with damaged paintwork on the stairway. The bath panel in the first floor bathroom is worn and becoming loose and Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 20 needs replacement. There are cracked tiles around the bath and grouting is stained. Residents’ bedrooms are free of clutter, have visual cues such as an astro ceiling and have soothing colour schemes and subdued lighting. Each resident has their own lounge/dining area which are equipped with televisions and/or a computer. The home does not have a separate laundry area. The washing machine in located in a wooden shed in the garden. This is not an ideal situation as it does not allow for a sterile environment with the walls and the flooring not wholly impermeable. Although there are laundry procedures displayed and a good practice poster regarding hand washing there is no room available for a wash hand basin. The shed is not lockable and there are substances hazardous to health (COSHH) unsecured. The deputy manager told us that the risk to residents had been assessed and considered low. It is recommended that as part of the kitchen refurbishment, consideration is given as to whether the washing machine can be moved to this area which would contribute to the principle of ordinary living. The tumble dryer is situated in the cellar which is accessed via a very steep stairway. The cellar is kept locked when not in use but unlocked when staff are in the cellar. Management state that this does not pose a risk to residents. We suggested to the manager that a risk assessment is carried out which consider hazards to both residents and staff. We saw some good infection control practice and some which required improvement. For instance, staff were seen to be wearing appropriate personal protective clothing when carrying out domestic tasks and washing their hands when leaving the kitchen. There were supplies of liquid soap and paper towels through out the building. However, there was a bucket and mop soaking in dirty water in the entrance to the kitchen. The cover to the ironing board was torn and stained. We recommended that sealed laundry baskets are used for the transporting of dirty laundry through the premises. Beaconhurst DS0000062601.V345867.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a caring and very motivated staff team. There are sufficient numbers of staff on duty to meet the needs of people. Recruitment and selection procedures are robust and offer suitable safeguards to residents. EVIDENCE: The manager told us that five of the current twelve staff employed hold an NVQ qualification and that the majority of staff are currently undertaking this qualification. During interviews staff confirmed that they were currently undertaking their NVQ. There is a range of specialist training which staff would benefit from and the manager told us that she is currently sourcing trainers. For example, only one person had undertaken a certificated autism course and training in epilepsy awareness. Nine staff have received training in physical interventions (SKIP) and some staff have also had training in understanding challenging behaviour. We also suggested that training is provided in the Mental Capacity Act 2005. During interviews staff demonstrated a good understanding of their role; they all gave examples of why they liked to work at the home primarily because of the residents and secondly because of their peers. Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 22 We looked at the duty rota and saw that since our last inspection staffing levels have been reduced due to the decreased needs of one resident. There are currently three staff on duty per shift with an extra member of staff on duty for at least five hours per day in order for residents to access the community. There are currently still two waking night staff on duty. The manager is supernumerary. Interviews with staff and observations made confirmed that these staffing levels are sufficient to meet the current needs of the residents. There are regular and well minuted staff meetings. It was pleasing to see that the main topic discussed was the welfare of individual residents. We looked at recruitment and selection procedures by sampling a personnel file of a new member of staff. Appropriate pre-employment checks had been carried out. For example, there were two written references and a full employment history. The person did not commence employment until a full police check had been received. We suggested to the manager that it may be beneficial to ask referees to add the date on which they complete their reference to ensure that it can be confirmed that this is received prior to the person commencing work. At present staff are not undertaking an induction and foundation training by an accredited learning disability awards framework (LDAF) provider. The manager explained that she has found difficulty in sourcing trainers. We saw that as a compromise staff were undertaking a full induction programme based on the common induction standards. We explained to the manager about the new learning disability award certificate which will be available to staff in December 2007. The manager said that she would seek further information. It is recommended that staff undertake training in equality and diversity. We looked at supervision records. Whilst staff are receiving supervision, the frequency could be improved in order to meet the National Minimum Standards. For example, one person has only received one supervision session this year. Annual appraisals have not yet taken place as the majority of staff have not been employment for over twelve months. Beaconhurst DS0000062601.V345867.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit home that is run in their best interests by a competent and skilled manager. Residents and staff participate in the running and development of the home although a formal quality assurance system has yet to be introduced. Practice and procedures are in place to promote residents’ health, safety and welfare. EVIDENCE: Mrs. Bebb is the registered manager and has worked at the home since July 2006. She has worked in the care sector for over fifteen years and has undertaken numerous courses and qualifications and keeps herself up to date with changes in legislation by undertaking statutory training along side her staff team. She is a certificated trainer in physical interventions. Mrs. Bebb told her that she has nearly completed her Registered Manager’s Award. Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 24 During interviews staff told us how the manager had made many improvements which had contributed to the improved quality of life for residents who live at the home, as demonstrated at the last two inspection visits. For example, one person said “before it was very regimental and there was no person centred planning, X does more activities now, there is freedom around the house and his bedroom is no longer locked when he is up, there is more choice and independence”. Other staff comments about the manager included: “every day I learn something new, step by step I learn, the manager and deputy helped me”, and “our manager is a very warm and very protective person”. We saw that there are regular staff meetings and that staff can raise issues to which the manager will listen and take action. Mrs. Bebb has an open door policy and during our visit both residents and staff were made welcome and clearly felt happy to approach her. Since our last visit there are regular reports from visits conducted by a senior manager. During interviews Mrs. Bebb gave examples of how she understands the principles of quality assurance. She told us that she had devised a model but unfortunately this had been destroyed when her computer became damaged. She intends to recreate this using the National Minimum Standards as a basis for measuring quality which is a good initiative. We sampled some maintenance and service checks and found these to be up to date. For example there are regular, recorded water temperatures. There are regular checks of fridge, freezer and cooked food temperatures. The deputy manager told us that the temperature probe is regularly calibrated and we suggested that this is recorded. We looked at the staff training matrix and cross referenced this a sample of training certificates. We saw that the majority of staff have received training in moving and handling and first aid awareness. Training has been booked for those staff who have not yet had training in infection control. Health and safety training was started but not completed due to a problem with a trainer. The majority of staff have completed fire safety training (there are three staff who still need to undertake this). Some staff had undertaken this training in 2005 and therefore would benefit from a refresher course. Beaconhurst DS0000062601.V345867.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 2 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 x 2 X 2 X X 2 X Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 26 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 20 Requirement To offer suitable safeguards to residents from abuse by ensuring that the identified resident has their own bank account, if a corporate appointee is necessary and money is paid into a central bank account, interest accrued must be calculated and paid to the resident with clear written records and procedures maintained. Timescale for action 01/11/07 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 YA6 Good Practice Recommendations It is recommended that residents’ needs are reassessed from time to time using a suitable assessment tool. It is suggested that there are systems in place to ensure that residents, their relatives and significant professionals are invited to participate in the six monthly review of their Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 27 care plans. It is recommended that a specific care plan is developed regarding how residents’ autism impacts upon their daily lives. To continue to pursue attempting to arrange educational opportunities for residents according to their needs and preferences. To improve record keeping with regard to daily activities and community access. For example to record any refusals or why changes to the originally planned activities, have taken place. To fully complete health action plans or the ‘Priority Health Screening Tool’. To check and record the temperature of the drugs cupboard to ensure that it does not exceed 25 oC. To clarify any ‘as directed’ dosages with the prescriber and ensure correct administration details are recorded onto the MAR sheets. To discuss within a multi-disciplinary team including the resident and Local Authority commissioners any extra contributions made by residents towards fuel costs and replacement meals and to include outcomes in the service user guide and residents’ individual contracts. All staff should receive training in safeguarding and protecting vulnerable adults. To complete the programme of redecoration and refurbishment through out the building. To consider whether the washing machine can be relocated from the garden to the kitchen area. To ensure that mops and buckets are not stored in the kitchen area when not in use and to ensure that mops are dried inverted. To consider obtaining sealed laundry baskets for transporting dirty laundry through the premises. To continue to pursue a range of specialist training for staff including autism awareness, epilepsy, and the Mental Capacity Act 2005. To provide training for staff in equality and diversity. To seek specialist accredited induction training for staff in learning disabilities. To provide staff with at least six recorded and formal DS0000062601.V345867.R01.S.doc Version 5.2 Page 28 2. YA12 3. 4. YA19 YA20 5. YA23 6. 7. YA24 YA30 8. 9. YA32 YA35 10. YA36 Beaconhurst 11. YA39 supervision sessions per annum (bi-annual). To continue to fully implement a quality assurance system which should include seeking regular feedback from residents, relatives and stakeholders. There should be an annual development plan for the home based on a systematic cycle of planning-action-review. It is suggested that fire safety training is carried out on a bi-annual basis (or at a frequency determined by the fire safety risk assessment). 12. YA42 Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Halesowen Office Ground Floor West Point Mucklow Hill Halesowen B61 8DA 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 Beaconhurst DS0000062601.V345867.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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