CARE HOME ADULTS 18-65
Bealey`s Lane Residential Home 1 Bealey`s Lane Bloxwich Walsall West Midlands WS3 2JT Lead Inspector
Lesley Webb Unannounced Inspection 12th October 2005 11:00 Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 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 Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 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. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bealey`s Lane Residential Home Address 1 Bealey`s Lane Bloxwich Walsall West Midlands WS3 2JT 01922 492285 01902 421 941 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) Swan Village Care Services Limited Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 5th May 2005. Brief Description of the Service: Bealeys Lane is a five-bedded care home for individuals with severe learning disabilities and challenging behaviour. It is owned by Swan Village Care Services Limited, which was established in 1988 to offer tailor-made services for adults with learning disabilities both in residential and day care settings. The home is located near to the centre of Bloxwich, opposite the park and close to shops, pubs and other amenities. The home was opened in 1995, originally being a residential dwelling, domestic in nature that has been converted for its present use. All the homes bedrooms are single without ensuite facilities. It has a bathroom and toilet on both floors, a large lounge, conservatory, kitchen, office and utility room. The home has parking facilities to the front of the building and a private garden to the rear with a patio area. The home also provides transport in the form of a mini bus with tail lift. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspector arrived unannounced to the home at 11.00am and stayed until 4.00pm. During the visit the service users were participating in various activities away from the home only coming back to the building for short periods of time resulting in the inspector only having short discussions and limited interaction with them. Due to this and the fact that the majority of people who live at the home having complex needs and communication difficulties the inspector spent additional time formally interviewing staff, talking to the manager and looking at records before giving feedback on the inspection process. Since the last inspection the manager has successfully completed her registration process to become the registered manager of Bealeys lane. This was the second unannounced inspection to take place at the home since April 2005 and interested parties should read this and the previous inspection report when looking at what National Minimum Standards have been assessed and outcomes achieved. The inspector would like to thank everyone for his or her co-operation and assistance during the visit, where she was made to feel very welcome by everyone. What the service does well:
The homes pre admission assessments are good, with evidence that information is sought from a variety of people in order that the home can be sure it meets the needs of prospective service users. Staff should be congratulated for the efforts they make to involve service users in decision-making processes despite barriers in communication. Everyone that the inspector spoke to demonstrated knowledge in this area, for example one member of staff said, “ its our responsibility to take time to get to know each person, understand their body language and facial gestures and respect any choices service users make”. All staff were able to give examples of each service users specific communication needs, which include the use of signs, behaviours and use of certain words. Despite the service users at Bealeys lane having communication difficulties the inspector found an abundance of evidence that service users rights and responsibilities are recognised and respected by staff, and that staff support individuals to understand these.
Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 6 The home should also be congratulated for the monitoring systems in place that ensure the health, safety and welfare of service users is promoted. All records seen by the inspector show that staff receive training in fire, moving and handling, first aid, food hygiene and health and safety and that regular checks take place for areas such as water, fire, risk assessments, maintenance of the building and equipment. 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. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 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 Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 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): 1, 2 and 5. The homes Statement of Purpose and Service User Guide are excellent, providing service users and prospective service users with details of the services the home provides, enabling an informed decision about admission to be made. Pre-admission assessment processes are good, ensuring the home can meet the needs of potential service users. EVIDENCE: The home should be commended for its efforts to produce a Service User Guide in a format suitable for the people it is intended for. Since the last inspection the home has produced this document in video format with many staff that work at the home participating in its compilation. The inspector viewed the video and found it to contain information about the home, its facilities and services, staff and their qualifications, activities and records. Staff that the inspector spoke to said that this had been an enjoyable event as well as providing information in a more suitable format. Since the last inspection a bed space has become available at the home and the inspector viewed documentation for a prospective service user who may take this place on a permanent basis. The inspector found that the information was comprehensive and covered all aspects of Standard 2 of the National Minimum Standards. When asking staff how they can be sure the home can meet the needs of someone when they move into the home all staff
Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 9 demonstrated knowledge in this area. For example one person stated, “ We try to get as much information as possible. Talk to their present carers to assess to see if they would be suited to this home. Find out about mobility, behaviour, and any special needs. Also we arrange visits to the home” A previous Requirement to ensure representatives of service users sign the contracts of residency on their behalf was found to be partly met with half of these now in place. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 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 and 7. Care planning is good, providing staff with the information they need to satisfactorily meet service users needs. Staff have a good understanding of service users needs, supporting them fully in decision-making processes. EVIDENCE: A previous Requirement to ensure care plans are reviewed with the involvement of service users at least every six months has now been met, with all files sampled evidencing that monthly key worker meetings occur with service users where care plans and discussed and reviewed. Person Centred Plans were also viewed and found to be in the main completed in full. However the inspector instructed that details of body language and facial expressions should be included as the majority of people who live at the home use non-verbal communication. The inspector also recommended that staff undertake training in Person Centred Planning in order that they have the appropriate knowledge for their implementation. The inspector asked all staff how they support service users with complex needs and communication difficulties to make decisions about their lives and
Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 11 life within the home. All were able to give examples of how they do this. For example one person stated, “ There’s information in their personal files, its important to read this to get ideas of their preferences and likes and dislikes. You need to understand the non verbal communication, talk clearly, giving the person time to respond” and “we look at peoples behaviours as indicators that they like or dislike something, one person will rip their clothes if they do not like something and another shows agreement with facial gestures. Its important that staff look at all signs and check what they mean”. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 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 and 16. Staff have a good understanding of the educational needs of service users, promoting life skills based on each persons capabilities. The rights and responsibilities of service users are well managed in this home, creating an inclusive atmosphere for service users at the home. EVIDENCE: A previous Requirement instructing that in-house and external activities be recorded in detail has now been met. All records relating to this viewed by the inspector demonstrated that service users lead full and active lives. The inspector asked staff how they support service users with complex needs and communication difficulties to further their education. Responses included “the needs of the people living here means that education is development of basic life skills such as cleaning their room. Even this can be difficult for some but even if means they hold a duster this can be an achievement” and “as well as going to a centre where they learn art and craft we try to encourage independency. For example when bathing we encourage them to do as much as possible for themselves, choosing their own clothes and learning to make a
Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 13 drink”. The inspector found that these comments reflected practices within the home. Records and practices seen on the day of inspection confirmed that daily routines are flexible, promote independence and choice. Staff were witnessed interacting with service users in a friendly yet respectful manner, respecting their wishes to be left alone or to join in with conversations. Conversations with staff confirmed that due to the level of risk identified for several service users no-one has a key to the front door or to their bedrooms but that two service users had been offered this facility, attempts had been made to support them to use these but had not been successful. Records seen by the inspector confirmed the contents of these conversations as true. It was also noted by the inspector that many documents produced by the home were in picture format and large print, in order to make them more accessible to service users. These included consent to open mail, information regarding managing finances and the complaints procedure. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 14 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. The health and personal care needs of service users are well met with evidence of good multi disciplinary working taking place on a regular basis. EVIDENCE: Five of the six Requirements identified in previous inspections relating to the health and wellbeing of service users have now been met by the home and the remaining Requirement partly met. Evidence was supplied that referrals to speech and language departments, assessments for wheelchairs, health action plans and annual health checks for vision, chiropody and hearing are all now taking place within appropriate timescales. The manager has also arranged communication training for staff (4 staff were attending this on the day of inspection) with a further date to be arranged for the remaining staff at the home. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 15 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. The home has a satisfactory complaints system with some evidence that service users and their representative’s views are listened to and acted upon. Generally the arrangements for protecting service users are satisfactory, further work in relation to financial arrangements will reduce the risk of abuse. EVIDENCE: The inspector noted that previous Requirements relating to Standards 22 and 23 have now been addressed. No complaints have been made since the last inspection. Records were viewed and found to meet National Minimum Standards. Certificates are now maintained in the home that confirm staff have undertaken Crisis Prevention Intervention training. The home acts as appointee for two service users and is in the process of completing applications to do this for two other service users. Personal allowance sheets and monies held in the home were sampled and all found to be in order, however the bank books for service users are held at the homes central office and were not available for inspection. The manager contacted the central office but no one was available to bring these to the home. The inspector also noted that the home is insured to hold a maximum of £70 on behalf of each service user but on the day of inspection this was being exceeded for some individuals. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 16 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. Recent investment has significantly improved the appearance of this home, creating a more comfortable and safe environment for those living there and visiting. EVIDENCE: Many of the Requirements identified in previous inspections relating to the environment have now been met. The carpets throughout the communal areas are being replaced on the 18th October 2005, broken cupboards have been replaced, paintwork throughout the home has been redecorated and broken floor tiles in the hallway have been replaced. The manager stated that new lounge furniture is being ordered once the decorating has been completed and the remaining Requirements will be actioned. The fire department carried out an inspection of the premises in May 2005 with all requirements identified actioned by the home. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 17 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): Not assessed at this inspection. EVIDENCE: Although not assessed at this inspection the inspector noted that the manager has now completed a training needs assessment for the staff team as a whole. A discussion regarding the contents of this took place with the manager agreeing to complete an impact assessment that identified the benefits of staff training, which will also inform future planning. Also all staff files sampled now contained evidence that they had undertaken equal opportunities training and that they had received an annual appraisal. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 and 42. Quality monitoring systems must be introduced based on the views of service users and other interested parties to ensure the home is meeting its aims and objectives. Health and safety is well managed in this home, creating a safe place for service users to live. EVIDENCE: The home has a quality assurance system that has been in place for approximately two years but never completed in full. The manager stated that the organisation was reviewing its quality assurance systems and going to introduce a new one that was both effective and of value to service users and staff. Despite this the home has obtained the views of service users and other interested parties and analysed these views and published the findings. The Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 19 manager agreed that the new quality assurance system should still include this information, incorporating the findings into a development plan for the home. All staff were asked, “How is your health and safety promoted at work?” All staff demonstrated knowledge in this area giving examples such as, “ there are many policies and procedures in place that we have to be aware of, we must always report near misses and repairs. Also there are risk assessments that we have a responsibility to read” and “the home has health and safety policies which we follow and courses which we must attend. We have to report hazards and adhere to policies such as wearing gloves and aprons, locking medication away and reporting faulty equipment”. Records viewed by the inspector confirmed that all staff either hold or are enrolled on mandatory training for fire, first aid, food hygiene, moving and handling and health and safety. In addition to this the manager and many staff have undertaken risk assessment training in order to extends their knowledge. All records relating to the maintenance and safety checks for the building were found to be in good order and up to date. A previous Requirement to develop the grievance procedure has now been met. The new procedure now includes timescales and information that includes notifying complainants of the outcome of investigations in writing. Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 4 3 X X 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X 2 2 X X 2 LIFESTYLES Standard No Score 11 X 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Bealey`s Lane Residential Home Score 2 3 3 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000020833.V257611.R01.S.doc Version 5.0 Page 21 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 YA5 Regulation 5(1) Requirement Timescale for action 31/01/06 2. YA6 15 3. YA18 12(1) 4 YA23 12(1) A representative of the service user must sign the contract on their behalf (REQUIREMENT ORIGINALLY MADE JULY 2002) – PART MET. Person Centred Plans must be 31/01/06 completed in detail with the involvement of service users (REQUIREMENT ORIGINALLY MADE MAY 2005) – PART MET All staff must undertake 31/01/06 communication training that is specific to the needs of service users (REQUIREMENT ORIGINALLY MADE MAY 2005) – PART MET The home must arrange for the 24/10/05 bank books of all service users to be viewed at CSCI Halesowen office The home must not hold more than the insured amount of £70 on behalf of each service user within the home or make arrangements to increase this amount with its insurers The easy chair used by S must be cleaned or replaced if the stains cannot be removed
DS0000020833.V257611.R01.S.doc 5. YA24 16(1) 31/10/05 Bealey`s Lane Residential Home Version 5.0 Page 22 6. 7. YA26 YA27 16(1) 16(1) 8. YA28 16(1) 9. YA28 16(1) 10. YA30 13(3) 11. YA35 18(1) 12. YA39 24 (REQUIREMENT ORIGINALLY MADE MAY 2005) All worn bedding must be replaced (REQUIREMENT ORIGINALLY MADE MAY 2005) The downstairs bathroom requires refurbishing (including replacing loose tiles, painting stained walls and putting a blind at the window) (REQUIREMENT ORIGINALLY MADE MAY 2005) The uneven flooring in the kitchen must be addressed (REQUIREMENT ORIGINALLY MADE MAY 2005) Two floor tiles in the kitchen must be replaced (REQUIREMENT ORIGINALLY MADE MAY 2005) Lids must be provided for the soiled laundry bins (REQUIREMENT ORIGINALLY MADE MAY 2005) The home must ensure a training needs assessment is completed for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning (REQUIREMENT ORIGINALLY MADE MAY 2005) – PART MET The quality assurance system must be implemented in full (REQUIREMENT ORIGINALLY MADE MAY 2005) 31/10/05 31/12/05 31/10/05 31/10/05 31/10/05 31/12/05 31/12/05 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 Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 23 1. 2. YA6 YA35 It is recommended that all staff undertake Person Centred Planning training It is recommended that the individual staff training and development assessments (known as profiles within the home) be completed in more detail in respect of developmental requirements that do not require formal training Bealey`s Lane Residential Home DS0000020833.V257611.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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