Inspection on 15/06/09 for Bealey`s Lane Residential Home

This inspection was carried out on 15th June 2009.

CQC has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CQC judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bealey`s Lane Residential Home 22/07/08

Bealey`s Lane Residential Home 21/01/08

Bealey`s Lane Residential Home 05/09/06

Bealey`s Lane Residential Home 12/10/05

Bealey`s Lane Residential Home 05/05/05

Bealey`s Lane Residential Home 12/11/04

Bealey`s Lane Residential Home 12/07/04

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 12/10/2009.

Key inspection report CARE HOME ADULTS 18-65 Bealey`s Lane Residential Home 1 Bealey`s Lane Bloxwich Walsall West Midlands WS3 2JT Lead Inspector Wendy Grainger Key Unannounced Inspection 15th June 2009 08:00 Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 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 F/P01922 492285 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 Miss Vicky Hill Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home Only (Code PC) To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Learning disability (LD) 5 The maximum number of service users who can be accommodated is: 5 22nd July 2008 Date of last inspection Brief Description of the Service: Bealeys Lane is a care home which is registered to provide care to a maximum of five people with severe learning disabilities. The service provider is Swan Village Care Services, part of the Minister Pathways Group. The home is located near to the centre of Bloxwich, opposite a park and close to shops, pubs and other amenities. The home was opened in 1995, originally being a residential dwelling and domestic in nature, that has been converted for its present use. All the homes bedrooms are single without en-suite facilities. 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. The information in the Statement of Purpose informed us that the current fees were between £1000 and £2515 per week. The reader may wish to contact the service for more current information. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 Star. This means that people who use the service experience Adequate quality outcomes. This unannounced key inspection was carried out by one inspector who used the National Minimum Standards for Care Homes for Younger Adults (18-65), and outcomes for people using the service as a basis for the inspection. Prior to the inspection we had sent an Annual Quality Assurance Assessment (AQAA) to the service. This is a self assessment tool it had been completed and returned to us within the timescale. The completion of the AQAA is a legal requirement and it enables the service to undertake a self-assessment, which focuses on how well outcomes are being met for people using the service. It also gives us some numerical information about the service. We saw that when the day staff had arrived for duty, they had a handover from the night staff before commencing the day. This enables information about the people using the service to be shared. The manager provided us with written information regarding staffing, training, menus and care plans. During our inspection the services line manager arrived and remained for the majority of the day. During the time she contacted various people to arrange for changes to be made regarding the environment. On arrival staff were seen and heard to assist people to rise and get ready for their day. Later each of the four people went out to Cannock Chase and then for lunch. Our inspection was planned to ensure that it did not disrupt the people’s routines, which is important to their lifestyle. We were able to observe people and had contact with one other person who had communication skills. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Behaviour guidelines have been put in place where necessary to help keep people safer. People are encouraged to personalise their bedrooms, this was evidenced when we looked at people’s rooms . New leather sofa’s have been purchased for the lounge. New wooden dining room table and chairs have been purchased for the conservatory area. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 7 What they could do better: The AQAA told us that decorating had taken place within the service but we did find areas that still required improvement. The system used to take medication out of the service for community outings and other visits could make people and staff vulnerable as it identified people’s prescribed medication. The storage for medication within the service did not fully promote the safe keeping of medication. The service had been waiting sometime for an agreement from the head office to follow up the recommendation made in the last key inspection (July2008) to provide privacy for the people by having appropriate window coverings in the lounge. A recommendation for the service to support people to open a bank account to maximise their finances has only been undertaken for one person. The service is waiting for a decision from head office about how the system is to operate to benefit the remaining people. We were unable to access regular staff supervision records, this practice the manager told us was not up to date. We were unable to access records of required Regulation 26 visits, this is a tool used by senior management to assess the service being provided and to provide on-going support to the manager in her role. The service should ensure that mandatory and relevant training is up to date this relates in particular to First Aid, Moving and Handling, and Health and Safety. See the follow up current information in the content of the report. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 8 If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 9 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.V375876.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who wish to move into the service receive all the information they require to make an informed choice about its suitability for them. People can be assured that the service can meet their needs. EVIDENCE: The completed AQAA we received prior to the inspection told us that the service had a full range of documents and contact with other professional agencies to ensure that the placement could meet the person’s needs. The service had a Statement of Purpose and service user guide. The service user guide is pictorial for ease of understanding. There were plans to provide the Statement of Purpose in a video format and possible a tape. Following the last key inspection the service had decided not to offer respite care. This will ensure that the people using the service did not have their routines disrupted. There have been no new admissions since 2004, at the time of this inspection the service had four long term people living there. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 11 The AQAA told us that a full needs assessment of needs would be carried out initially by the manager. The person, their family, advocate or other professional would be encouraged to visit the service as often as they needed. They would be able to discuss issues with the manager or staff on duty. From this assessment a care plan can commence and built on with risk assessments when the person had been admitted. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can be assured that a support plan is in place to meet their needs. EVIDENCE: We were told that the support plans are reviewed and updated when necessary. We saw that these support plans contained, risk assessments and medical files. The support plans are ‘person centred’ and include goals and the needs of individuals. They are reviewed with social workers, and families if applicable and possible. We were told that these support plans are explained to individuals in a manner that was thought they could understand. The majority of the staff have been Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 13 employed for a number of years and are experienced in meeting the needs of the people. We looked at one persons support plan chosen at random by the manager. The format was lengthy but detailed. We discussed why there a need to create a support section if the person did not require that particular support. We saw in the plan that referrals had been made to other agencies to provide extra specialist input for example, one person had had behaviour guidelines written with input from the Walsall behaviour team and the manager. The plan contained details of family contacts although we were told this is limited and these details many not be current. We saw that during a review a person had indicated that she liked her room, holidays bowling and swimming but there was no evidence of her participating in the interests. There was evidence of her getting on with others, her likes and dislikes for food and dressing. The support plan contained a number of risk assessments all of which were reviewed. During the last twelve months the service had reviewed the daily recording process, these were seen to be detailed identifying the persons daily routine including activities offered and refused by the person. We were told that people are explained too and supported in a manner to which the staff felt was appropriate and understandable to the person. Within the group communication is limited, with only one person having good verbal communication skills. We spoke to one staff member who was aware of the procedure to follow if she had concerns about any aspect of care or the service. She confirmed Protection of Vulnerable Adults (POVA). She was aware of the needs and personality of the one person in the home during the afternoon, we saw that this person was comfortable in her presence. We observed staff during our inspection they demonstrated their commitment, knowledge and understanding of the people. In particular during an incident, which occurred during the afternoon. During the incident staff distracted the person and dealt with the situation commendably. Our last inspection had concerns that one person’s needs were not being fully met. The service had reviewed and sought advice and guidance from other specialist agencies with additional support being provided. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 14 Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 15 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): This is what people staying in this care home experience: 12,13,15,16,17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service would be offered opportunities to suit their preferred lifestyle and individual personalities. EVIDENCE: The services completed AQAA told us that activities are offered on a daily basis. Holidays are provided with a financial contribution from the provider. The service can access the community via the mini bus. We saw that this vehicle was without identification so promotes the dignity and privacy of people using the service. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 16 Choices for people are based on occasions by body language, expressions, self harm and pulling away. From these exhibits by individuals’ staff interpret that the choice explored is not accepted by the person. We did observe one person sitting alone in the lounge while staff continued with the laundry and other staff were engaged. This person did not appear to be disturbed by being alone and later came into the garden to the staff. Integration into the community was experienced during our inspection with all the people going to the Chase to collect bark for the garden and then out for lunch. We were told by one person what he had chosen for lunch and that he had enjoyed it. No person attends any of the local colleges. Holidays were being discussed for one person, last year two people went of two holidays. One person chooses not to go away but enjoys day trips out. People where applicable are encouraged to maintain contact with family and friends, one person on occasions has planned leave with his family. People are encouraged to have a healthy and nutritious diet, menus seen were pictorial there were plans to develop the size of the pictures making it easier for the people to read and understand. We saw evidence in the plans that cultural diets were considered. We were told by the manager that the two people who had an alternative religion and culture would be unaware of either. It was suggested that the service contacts the family of one person to ascertain the personal needs to further promote choice and meet cultural and dietary needs The required checks for the water and food probe temperatures had been omitted. We were told that the probe was broken, although the cook had for days put ‘piping hot’ for the food served. The fridge and freezer temperatures were current. The lack of working equipment could put people at risk in the event food is produced at an inappropriate temperature. We were aware from discussions that one person, who later spoke to us and confirmed this, that they helped with the shopping and put things in the basket. This person told us that he liked food such as cereals. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The people using the service were provided with support with their health needs. Medication storage and equipment used were inappropriate which could place people at risk. EVIDENCE: The AQAA told us that ‘individuals privacy and dignity was respected at all times. Initial health profiles and action plans were in place. One to one support is provided for daily personal care’. We observed that people were well presented, in appropriate clothing for the weather when they went into the community. We observed one person demonstrate a strong emotional outburst. The staff dealt with the situation on a well-informed basis, aware what was required to assist the person while being proactive in meeting his needs to neutralize the situation and ensuring the safety of other people. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 18 No one person had the ability to self-administer their medication. The support plan seen identified that annual health checks and intervention by other health agencies had taken place since our last inspection. The services completed AQAA told us that ‘medication was stored in accordance with guidelines’. So we were worried when we identified that this was not correct. We saw a medication storage facility that was a ‘locked wooden domestic cupboard’ that despite the lock it be easily opened. We saw staff taking medication out into the community to be administered at lunch time. The container they used was secured with tape at the base and one of the catches was broken. The label on the container identified each individual person’s name. Our concern for the safety of the staff using this container was fully discussed with the person in charge after which the staff transferred the medication into a small metal box, which would fit in a bag. We asked advice from one of our pharmacists about this, who advised that if medication was taken out on a regular basis for example to day centres, the service needs to approach their pharmacy to provided labelled named bottles. We were told that the service had on order a metal trolley but there was no delivery date for this trolley. We told the manager that the trolley will need to be secured to the wall when not in use. The lack of approved medication storage we identified in our last report of 2008 and recommended that suitable storage should be provided for medication which still has not been achieved. The service has protocols for the administration of medication for medications prescribed as ‘when required’. We did see the medication administering record. We were unable to observe the staff administering medication as the lunchtime medication was administered when they were in the community with the people. We were told and staff confirmed in the records that they had received training for the administration of medicines to ensure that medication was administered for the safety of the people. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have access to a clear, pictorial, complaints process. The service protects the people by making sure that staff are knowledgeable about protection of vulnerable people processes. EVIDENCE: The services completed AQAA told us that the service has various formats for the complaints process which are explained to the people who use the service. The service takes complaints seriously and any concern, complaint or allegation is followed up by the management and reported to the appropriate agency. The folder is audited on a three monthly basis. Staff records for training, the AQAA and staff confirmed to us that they had received training in the protection of adults (POVA) we identify that the training included the majority of the staff and more was planned 2009. The pictorial complaints procedure was displayed in the home in a case with a Perspex cover, it was advised that the polystyrene tiles in the case should be Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 20 removed as they were a possible fire hazard and could put people at risk. Further complaints processes were contained in the Statement of Purpose and Service Users Guide. We had received no complaints about the service. There has been one referral to the safeguarding team an allegation had been made in February 2009 had been dealt with and found to be inconclusive. An action plan put in place we were told appeared to be working for the person. Part of the plan was seen during the inspection. The person was very aware of the terms that he was to follow to ensure his behaviour did not give concerns. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 People using the service experience Adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements are needed to make sure that people using the service live in comfortable and well maintained home that promotes choice and privacy. EVIDENCE: The service is located in a quiet road near the centre of Bloxwich by a park and a public house. The building is detached. Parking is available at the front of the service with a small, but well utilised garden space to the rear. The services completed AQAA told us that the service is ‘bright clean and free of odours, it is plain, this is based on the risk involved with the people’. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 22 We looked at the premises, the bedrooms were personalised to suit individuals, risks and personalities. We did however, observe unacceptable fittings for a sink in one bedroom while there was a tendency to flood, alternative fittings for the taps should have been explored. Two wash hand basins were in a poor condition. One had a crack the other badly stained. The tap in one bathroom was loose and moved when turned on. These conditions were a potential hazard for the people using them. One person’s mattress had a large split in it, this was dealt with by the area manger during our inspection who arranged for a replacement. Since our previous inspection the service had purchased new leather settees for the lounge, new dining room chairs and table for the conservatory which is used as a dining room. The lounge decoration did not provide the people with a living area that was pleasurable, comfortable or relaxing area. Decorating had been commenced by the staff and left unfinished. The colour was uninteresting and of a poor quality, with patches of the previous colour showing through. The laminate floor covering was badly marked; although this was identified in March 2009 by the area manager during a visit, it remains the same. The maintenance person had recently varnished the new dining room table but the cover was thick and uneven. We highlighted this to the area manager during the visit. Our last key inspection of 2008 identified the ‘lack of privacy’, a recommendation was made to ‘take further action to provide people with window covering promoting their privacy’. We were told that a request had been made for tinted windows. No action has been taken by the company. This means that people continue to have limited privacy in the lounge. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32 34 35 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were cared for by committed staff who try to meet their welfare and lifestyle needs. The service does not always provide the mandatory training required to ensure the staff have appropriate skills and good knowledge base. EVIDENCE: The services completed AQAA told us that ‘staff had been employed at the service for a number of years giving continuity for the people using the service’. Two staff had left employment in the previous twelve months. We were told that the service hoped to employ two new staff when the required Criminal Record Bureau (CRB) and Protection of Vulnerable Adults (POVA) checks have been returned. Staff are provided with the terms and conditions. Induction Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 24 training is provided to enable the mix of skills of staff to further support the people at the service. We were told that the services budget allows five days, for the training of staff. A probation period of three months is part of the contract for new staff. The services recruitment process is robust and involves adverts with an agency that filters prospective staff. Records for two staff identified that all the required checks which include Criminal Records Bureau (CRB) and Protection of Vulnerable Adults (POVA), two references, application form and identification were carried out prior to employment. We spoke to one of the afternoon staff who confirmed she had received training to protect the people from any abuse, she was aware of the complaints process and would not hesitate to report any concerns to the manager or to a higher person in the company or us. Another staff spoken with confirmed that she had received training for the protection of the people, medication training and had achieved the National Vocational Qualification (NVQ) level 2. Staff rota’s identified that staffing levels were currently three support staff with the manager on duty for the mornings, these staff would be supported by the catering person, driver and maintenance when necessary. The afternoon shifts were three staff and management. The night staffing levels consist of two waking staff with an on call. We had concerns to the mandatory training provided to staff, records identified that not all the mandatory training was current. These included First Aid, 2003 for two night staff, Moving and Handling, Health and Safety. The lack of training could put people using the service at risk. We were told by the area manager that there had been no funding for the service via Walsall Council, no free training had been identified. This was discussed during the inspection with management that the company need to explore other sources for training. The number of staff trained to National Vocational Qualification (NVQ) is above the recommended minimum of 50 . Other records identified that fire training was planned for 1st July or two sessions this will be mandatory for all the staff to attend. The majority of the staff had been trained supporting Autism, safe handling of medication. The majority of staff had completed Adult protection. The management needs to review the records and identify the areas where staff required training or refresher courses. Since the inspection we have been contacted by the manager to inform us of planned training dates which include, First Aid 23.6.2009 Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 25 POVA 26.6.2009 Moving & Handling 2.7.2009 Infection Control Distance Learning Health & Safety Distance Learning 28.6.2009 six staff enrolled. The manager and senior staff have enrolled onto a leadership management course. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37 39 42. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People using the service are supported by an experienced manager and a committed staff team. Management are not always supported by the relevant paperwork and support from senior management which could have an effect on the service. EVIDENCE: The services completed AQAA told us that the manager had had eight years experience of working in the caring profession. This was confirmed by the Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 27 manager during our inspection. She had a number of qualifications including National Vocational Qualifications levels 2, 3, and 4. An application has been made for her to commence the ‘Leadership Management Award’. The manager had completed the Annual Quality Assurance Assessment (AQAA) for us prior to the visit. The document was informative and provided details about the service and numerical details about the staff and servicing of equipment, policies and procedures. The service has a quality assurance system in place. This audit is part of the organisation support from the company. We were provided with a copy of one of the required monthly visits completed on the 18 March 2009. We were told that there had been another visit in April 2009 but no evidence of this could be identified. Records show that these visits, while contact may have been made no current records could be provided. The manager was not receiving consistently the support of the company that would have identified during supervision the need for training and the environment and recommendations that had not been addressed from the previous inspection in 2008. Satisfaction surveys were sent to families where possible when they are returned they are collated and any comments acted upon. We evidenced from discussions with the manager that supervision for the staff during her long term leave had not been consistent and since her return had not caught up. She agreed that this is an area where more planning is needed. We evidenced from the records and information in the AQAA that the fire procedures were placed around the service. The service had moved forward in expediting regular fire drills on a monthly basis with staff signing as individuals confirming their attendance. Records identified that three weeks for testing the system were not completed. It seems the person responsible was on annual leave. This responsibility needs to be taken up by another member of staff when necessary. We were told and evidenced a bag of essentials in the porch in the event of an emergency and evacuation. None of the people manage their own finances, the records were checked and found satisfactory, and monies are checked and signed for three times each day by staff. We checked at random and found the records and funds accurate. The previous report in 2008 made a recommendation for individuals to have bank accounts in the best interest of the person. This has not been followed by the management or company. One person from the Sandwell area has an appointee, monies are requested and then staff collect the funds. The company has closed the pooled account. There are no projected plans to maximise peoples’ personal monies via an account that incurs interest so will need further consideration. Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 28 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 1 25 x 26 x 27 x 28 x 29 x 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 X 3 X X 2 2 Version 5.2 Page 29 Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13 Requirement To make sure that no person is placed at risk suitable secure facilities for the storage of medication must be provided approved equipment must be available when medication is taken out of the service. Timescale for action 02/08/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA23 Good Practice Recommendations The service should support people who use the service to open a bank account to maximise their finances The service should ensure that the home is furnished and decorated to a good standard. The service should ensure that further action is taken to DS0000020833.V375876.R01.S.doc Version 5.2 Page 30 2. 3. YA24 YA24 Bealey`s Lane Residential Home provide service users with window covering, therefore promoting their privacy. 4. 5. YA42 YA36 The service should ensure that all mandatory training is up to date this includes manual handling. The service should ensure that all staff receive 1:2:1 supervision sessions on a regular basis, the minimum standard recommends 6 times per year. The service should ensure that staff given the responsibility to supervise staff have the confidence and have received the training to do so. The service must ensure that the manager receives the support and supervision necessary to ensure that the service is effectively managed for the benefit of service users. 6. YA36 7. YA43 Bealey`s Lane Residential Home DS0000020833.V375876.R01.S.doc Version 5.2 Page 31 Care Quality Commission West Midlands Region Citygate Gallowgate Newcastle upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Fax: 03000 616171 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. 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