Inspection on 21/01/08 for Bealey`s Lane Residential Home

This inspection was carried out on 21st January 2008.

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

Other inspections for this house

Bealey`s Lane Residential Home 15/06/09

Bealey`s Lane Residential Home 22/07/08

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 08/07/2008.

CARE HOME ADULTS 18-65 Bealey`s Lane Residential Home 1 Bealey`s Lane Bloxwich Walsall West Midlands WS3 2JT Lead Inspector Mandy Brassington Key Unannounced Inspection 21st January 2008 10:00 Bealey`s Lane Residential Home DS0000020833.V340508.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 Bealey`s Lane Residential Home DS0000020833.V340508.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. Bealey`s Lane Residential Home DS0000020833.V340508.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.V340508.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 5 September 2006 Brief Description of the Service: Bealeys Lane is a five-bedded care home for individuals with severe learning disabilities and complex behaviour, one bed is for respite service provision. 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, domestic in nature that has been converted for its present use. All the homes bedrooms are single without en-suite 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. The home provides limited activities in the home and the community, to support the development of life skills or to meet the diverse needs of individuals. The Service User Guide on 21 January 2008 recorded that the weekly fee level for the home was between £1,000 and £2515, including £300 towards the cost of an annual holiday. The Acting manager confirmed this to be accurate. Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was an unannounced key inspection and therefore covered the core standards. The inspection took place over seven hours by one inspector who used the National Minimum Standards for Younger Adults as the basis for the inspection. Prior to the inspection the Acting manager completed an Annual Quality Assurance Audit (AQAA) for the Commission for Social Care Inspection. People who use the service have severe learning disabilities and very complex needs; comments and questionnaires were not received from individuals. Questionnaires were sent to professionals associated with the service; no response was received. A tour of the home was undertaken. On the day of the inspection, the home was accommodating four people. The inspection included an examination of records, indirect observation, discussion and observation of four people who use the service, and four staff on duty. Three Care Plans were examined along with three staff records. Observation of daily events took place. Inspection of the storage system and medication procedures were inspected. Fourteen requirements and three recommendations were made as a result of this visit. This is an overview of what the inspector found during the inspection. The quality rating for this service is O Star. This means that people who use the service experience poor quality outcomes. What the service does well: The home is an ordinary house in a residential area of Walsall, with large communal areas and single bedrooms. Individuals are able to choose which parts of their home they use and can spend time alone. People who use the service are able to continue and develop close relationships with family and friends and can receive visitors to the home or are supported to visit the family home. Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 6 The home has robust recruitment procedures to ensure the protection of individuals, and all required pre-employment checks are carried out including obtaining a Criminal Records Bureau Check (CRB). Staff receive a comprehensive induction in line with the Skills for Care Council recommendation and staff have access to good training opportunities. What has improved since the last inspection? What they could do better: The home needs to review how activities are provided both in the home and the community. People who use the service have very limited opportunities for stimulating structured activities in the home. Currently people spend most of their time asleep or watching the television and listening to music or playing with toys. Community activities in January consisted mainly of accessing health care services and driving out in the minibus. After consultation with people who Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 7 use the service, meaningful activities, including opportunities for education need to be explored and provided. Following a review of care and guidelines by the Behavioural Support team, the registered person needs to ensure that suitable staff support is provided to all people, to ensure activities and outings can be conducted. Fire evacuation systems and suitable Fire doors need to be provided to ensure that in the event of a fire, staff can support people to safely evacuate from the home. All Fire exits need to have suitable locks fitted in line with recommendations from the Fire Officer. Further training and support is required to ensure that all staff who are responsible for administering medication can do this safely. The home has suitable Procedures in place that staff must follow, to ensure people receive the correct medicine at the right time. Due to the poor outcomes for individuals in relation Lifestyle, Personal and Health Care and Conduct and management of the home, and unmet requirements from the previous report, the home will be subject to a Management review by us. A management review is a key part of the enforcement process whereby we set out what we will do to get the care provider to improve their service. The action we take, will depend upon what effect this is having on the people using the service and how the care service provider responds. 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. Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 8 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.V340508.R01.S.doc Version 5.2 Page 9 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, 2, 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has developed a Statement of Purpose and Service User Guide, which includes a contract of terms and conditions. The accommodation provided needs to reflect the current service provision to ensure people have an accurate picture of the service. EVIDENCE: The Statement of Purpose and Service User Guide had been reviewed to reflect the new Service provider, and changes to contact details for the Commission for Social Care Inspection. The documents included details of the home’s provision and a contract with terms and conditions of occupancy. The contract included details of the fees payable and what is included. The Statement of Purpose recorded there was a bathroom on the first floor for use of people who use the service. This door was locked and staff stated that this was the staff bathroom, but is used by one person who used the service. The room was decorated differently from all other areas of the home and not suitable for the needs of the people in the home. This bathroom is for use for Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 10 people who use the service and was included in the registration of the home and detailed within the Statement of Purpose. The service provider must ensure that the bathroom be made suitable for use by people who use the service. There have been no new admissions to the home since the last inspection. Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 11 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, 8, 9. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans are person centred and are agreed with the individuals where possible. Staff have used variety of ways to help individuals express their needs, although the care plan does not consistently reflect the care being delivered in relation to daily activities. EVIDENCE: Each person had a large plan of care with information supported with photographs and pictures. The plan included a personal profile, and details of written in the first person, ‘things I like and don’t like’, ‘how I get on with others’, ‘how I communicate’ and ‘behaviour if sick or unwell’. One person had a detailed plan using photographs, to show facial expressions and actions, including an explanation of each picture written in the first person. Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 12 All individuals had a support plan, which recorded details of how staff were to support people, including whether one to one support was required, communication, liaising with family, consent to medication and details of current medication. Where possible people who used the service or their representative had evidenced their involvement. Assessments of risk were on file for any identified complex behaviour, driving in the car, eating, bathing and some community activities. Discussion with staff confirmed they were aware of the plans, and through discussion demonstrated a good knowledge of support needs. Key workers and link workers completed a comprehensive monthly review, covering complex behaviour, social interactions, activities, finances, any concerns and reviews. In January, staff began a new daily recording system. The manager reported that this would be reviewed; it included separate areas to record support given with life skills and daily activities. The plans were very large and contained a vast amount of information. Discussion took place with the Acting Manager regarding having a concise working plan that would be more accessible, and clearly identify support needs. The Acting manager agreed that a large amount of information could be filed separately. Staff stated that people are able to choose their daily activities, but from observation and discussion with staff, it was noted that decisions were being made due to the staff support for one individual, and based around the needs of the same person. Management strategies were in place for one person who used the service and dated July 2004. The plan had been reviewed but stated that no changes to the plan. On the day of the inspection, the Behavioural support team visited the home to observe the person and to assess the current situation. Staff reported this was the second visit and support guidelines were to be produced. It is a concern to us that activities and opportunities for people who use the service are dependant upon the behaviour of one person living in the home. It is required that the staffing and support provided in the home be reviewed to reflect the support of all people, in relation to lifestyle and activities. This is further addressed within the Lifestyle Outcomes for people who use the service. Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are limited opportunities for people who use the service to be independent and involved in community activities, and people are not supported or encouraged to follow educational interests or activities in the home. EVIDENCE: The previous visit required that the registered person must support individuals to become part of, and participate in the local community, in accordance with their assessed needs, and to ensure that individuals have access to, and choose from a range of appropriate leisure activities. Inspection of records, discussion with staff and from observation demonstrated that people who use Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 14 the service have very limited opportunities for activities in the home and the community. Inspection of daily records of all people who use the service, demonstrated that during the month of January 2008, individuals have only been out of the home on a maximum of three occasions; staff confirmed this. For two people, one visit was to receive treatment from a chiropodist, and the other outings were in the home’s minibus. One file recorded that one person went personal shopping but did not get out of the van. Activities in the home have consisted of playing with rattles or toys, closing doors and windows, staying in bed, listening to music or watching television and DVDs. Discussion with staff revealed that one person in the home exhibits complex behaviour, which may be worse when others are involved in activities or when out with other people. The Behavioural support team are now supporting the home and developing new management strategies. The home must ensure there is sufficient staffing in the home, to provide activities and support to all people to carry out meaningful activities in the home and the community. On the day of the inspection, one person stayed in bed until late afternoon. Inspection of records and discussion with staff revealed that this is a usual daily event. Staff reported that ‘he’s always like this in the winter’. A review of the person’s health and mental health needs is required. Daily activities were also discussed with staff and the Acting Manager, as when the person does arise, the reports documented that the main activities were opening and closing doors and windows, and playing with rattles and toys. We examined the Contract for each person, which clearly recorded the home would facilitate access to health care, and provide opportunities for exercise and physical activities. The service is required to consult with people who use the service, and provide arrange of activities in the community and in the home in line with agreed contracts and plans of care. It is a serious concern to us, that people have poor opportunities in the home and community for activities and community participation. The contract price included a three hundred pounds contribution to a holiday. Staff reported that one person did not have a holiday or equivalent outings. This money was allocated as part of the agreed contract with the person and placing authority and must be reviewed to ensure this is provided. The menu was displayed on the notice board and used photographs of the meals to be served to support individuals to make a choice. Staff reported that meals are flexible and people are able to choose what they want to eat at each meal time. Bealey`s Lane Residential Home DS0000020833.V340508.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, 20. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. People who use services have access to health care services both within the home and the community. Medication administration practices are not robust and the current practice could place people who use the service at risk. EVIDENCE: People who use the service had a Health Action Plan in which a record of appointments, correspondence and any outcomes were recorded. Where people had a specific diagnosis or any medical condition, an information sheet was included to support staff understanding. Dispensing leaflets of medicines were on file to ensure staff were aware of its usage and possible side effects. As recorded within the Lifestyle outcome group, on the day of the inspection, one person stayed in bed until late afternoon. Discussion with staff and inspection of records revealed this is a daily occurrence. Discussion took place Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 16 with the Acting Manager regarding the person’s mental well being, and the need to carry out a review with health care professionals, in addition to review the opportunities for people to engage in activities and have a purpose to get out of bed. The Contract for each person, clearly recorded the home would facilitate access to health care. It is a concern to us that the service has not reviewed health needs and provided stimulating activities. On the day of the inspection, one was person was unwell. Staff were observed responding appropriately, assessing the situation, and providing sensitive and personal care. The person was able to spend time in their room to recover before choosing to spend time downstairs with other people. All people were well presented and dressed in a style of their choosing. It was evident, that staff have ensured that individuals are able to receive support to address personal care issues and personal hygiene. Medication was stored in a closed box within a locked cupboard in the office. The Monitored Dosage System was used (MDS). On the day of the inspection, the community Pharmacist carried out a planned audit of medicines and systems. The Medication Administration Records included a photograph of the person and where ‘as required’ (prn) medicines were needed, there was a protocol for its use. During the inspection, staff were observed on two occasions dispensing medicines from the blister pack without referring to the MAR sheet and signing each MAR Sheet entry prior to the medicines being administered. This was discussed with the Acting Manager, who confirmed this practice does not comply with the homes procedures for safe administration of medication. Staff need to receive support and training, to ensure all medicines are safely administered, and staff sign the sheets when they can evidence the medicines have been taken. Bealey`s Lane Residential Home DS0000020833.V340508.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, 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a complaints procedure that is clearly written and easy to understand and is displayed in within the home. The policies and procedures for Safeguarding Adults are available and staff know when incidents need external input and who to refer the incident to. EVIDENCE: The home has a complaints procedure that is clearly written and easy to understand using a suitable system of pictures. The complaints procedure is displayed in the home. Staff have received training for safeguarding adults, and through discussion staff demonstrated an understanding about when incidents should be reported and how to respond to an alert. There has been one safeguarding referral since the last inspection and staff responded appropriately and provided information to external agencies when requested. Appropriate notification of the incident was sent to us. We inspected two people’s personal finances, which demonstrated that money is suitably recorded and audited each day. Discussion took place with the Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 18 Acting Manager regarding exploring how people could open their own bank account, as all the person’s money is kept in the home. Bealey`s Lane Residential Home DS0000020833.V340508.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, 25, 27, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that meets the specific needs of the people who live there. The home is comfortable and people can personalise their rooms. Some areas of the home need to be redecorated to provide an improved environment for people, and to be able to access all areas. EVIDENCE: The home is an ordinary domestic house that provides a large communal lounge and dining area in the conservatory. Each person has their own room, which they are able to personalise to reflect their interests. Due to the complex needs of people who use the service, pictures and small furnishings are secured. Staff reported that furnishings need to be of a specific design, as the fabric would be torn if there are weak areas. Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 20 The paintwork in all parts of the home is poor and needs to be repainted. The paintwork is also sticky to touch; Staff reported this is due to the cleaning products used in the home, though is now difficult to clean. It is required all areas be repainted to a suitable standard. The kitchen work surfaces have large areas that have been scorched and need replacing. The registered person must consult with Environmental Health and arrange an inspection of the premises to be carried out, to ensure suitable standards are maintained. There is a separate laundry area on the ground floor. Discussion with staff revealed that where any linen or clothing is soiled, red alginate bags are used in the domestic style washing machine and may stain people’s clothes. Where there is a need for sluicing equipment, this must be provided. The service provider must provide equipment with a sluice facility to meet the needs of people who use the service and to meet infection control standards. There is one bathroom and separate toilet on the ground floor. The bathroom on the first floor was referred to as the Staff toilet. The Statement of Purpose recorded that this was registered as part of the home, for use by people who use the service. Staff stated that one person uses this under staff supervision and it is not suitable for other people in the home, as there are unfixed objects and the windows are not fitted with safety glass. It is required that this area be made suitable for all people who use the service. The previous visit identified uneven slabs around the home, discussion with staff revealed this had been addressed although inspection of the exterior revealed that this problem had re-occurred. Staff confirmed these were hazardous to people who use the service, staff and visitors. It is required that this be addressed and made safe. Bealey`s Lane Residential Home DS0000020833.V340508.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, 34, 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service has a good recruitment procedure for the protection of individuals, and staff are supported through a comprehensive induction and training programme. EVIDENCE: On the day of the inspection the staffing in the home consisted of:The Acting Manager worked from 8.30am – 4.30pm 1 Senior Care working from 6.45am –2.15pm 3 support workers from 7.00am – 2.00pm In the afternoon there consisted of:1 senior care working from 1.45pm – 9.45pm 3 support workers from 2.00pm - 9.00pm Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 22 At night there were two night care workers from 9.00pm – 7.00am. The Acting Manager confirmed this was the usual pattern of working in the home. Inspection of three staff records demonstrated all required pre-employment documentation, including a copy of identity, appropriate work permits, two references and a satisfactory Criminal Records Bureau Check (CRB) was in place to ensure the safety and welfare of individuals in the home. Staff have received an induction in to the home that included completion of the Skills for Care Common induction standards. Staff stated they have good opportunities to attend training and receive five days paid training per year. Inspection of staff records confirmed that staff have attended training for Safe Administration of Medication, Equality and Diversity, Health and Safety, Moving and Handling, Safeguarding adults, Non-violent crisis intervention and Older People with learning disabilities. The Acting Manager reported that 75 of staff have achieved and NVQ Qualification, which exceeds the recommended standards for residential homes. The home has a copy of the Mental Capacity Act, but staff have not received any training. Staff confirmed they are unaware of the Act and the implication for people who use the service and practices in the home. It is required that staff receive this training. Staff have worked within the service for a number of years and during group discussion, it was evident that people are committed to providing a good service under difficult and challenging circumstances. Staff were aware of each persons needs and support and spoke passionately about improving the service for all individuals. There is little diversity in the staff team and its composition does not reflect the culture or gender of people using the service. Discussion with the manager demonstrated a knowledge and an awareness of people individuals needs including people’s cultural and religion and how this could be met within the team. As discussed within outcomes for people in relation to Individual needs and choices, a review of staffing is required to demonstrate how the service is able to meet the needs of individuals in relation to Lifestyle and activities, and agreed behavioural support. Bealey`s Lane Residential Home DS0000020833.V340508.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, 42. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The service provider understands person centred planning, though translating this theory into practice is variable resulting in people having limited access to resources in the home and community. Fire evacuation procedures and equipment has not been reviewed in line with recommendations and has placed people at risk. EVIDENCE: The registered manager was absent from the home for an arranged period of time. The service provider had recruited an Acting Manager to cover the agreed period of absence. Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 24 The service had completed their first annual quality review and has sought views from people who used the service, professionals and family members. There was no evidence of a developmental plan based on the findings or the review. It is recommended that a developmental plan be produced and to demonstrate how this has influenced care provision. The Acting manager completed the Annual Quality Assurance Audit (AQAA) for us prior to inspection of the home. Due to the complex needs of individuals there were no completed surveys from people who use the service. All sections of the AQAA were completed and the information gives a reasonable picture of the current situation within the service. The acting manager had ensured that all maintenance work, repairs, annual checks, testing of equipment and regular fire drills were undertaken. A record of all tests was included within the AQAA. The front entrance to the home is a Fire Exit. A Star Key locks the first door into the porch, the second door is bolted from the inside and has a chubb style lock fitted. The West Midlands Fire Service visited the home in July 2006 and identified the exit doors were being locked with a Key as an area of concern, and reported on suitable locks to be fitted. The service provider took no action. It is required that locks be fitted to the front entrance in line with the recommendations of the Fire Service, to ensure that people in the home are not placed at risk, and systems are in place for the safe evacuation of people who use the service. Following the previous visit by us, the registered person has not met all requirements, particularly in relation to providing a stimulating and varied lifestyle for people who use the service. The plans of care contained good information about individual’s needs and preferences and managing complex behaviour, though this has not been translated into practice to make a difference to outcomes for people using the service. Due to the poor outcomes for individuals in relation Lifestyle, Personal and Health Care and Conduct and management of the home, and unmet requirements from the previous report, the home will be subject to a Management review by us. A management review is a key part of the enforcement process whereby we set out what we will do to get the care provider to improve their service. The action we take, will depend upon what effect this is having on the people using the service and how the care service provider responds. Bealey`s Lane Residential Home DS0000020833.V340508.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 3 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 2 25 3 26 X 27 2 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 1 13 1 14 1 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 1 X 3 X 3 X X 1 X Bealey`s Lane Residential Home DS0000020833.V340508.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA6 Regulation 15(1) Requirement People who use the service must be provided with support to achieve the agreed plan of care and contract with the service. People who use the service must be supported to participate in the local community according to their agreed plan of care and contract. This requirement is unmet from visit 05/09/06 People who use the service must be consulted regarding the provision of suitable activities in line with the plan of care and contract, are provided in the home and the community. This requirement is unmet from visit 05/09/06 The agreed contract states a contribution towards a holiday is part of the fees. This must be reviewed to ensure the person receives a holiday or equivalent as agreed. Timescale for action 21/02/08 2 YA13 16 (m) 21/02/08 3 YA14 16 (m)(n) 21/02/08 4 YA14 16 (2)(m) 30/03/08 5 YA19 12 (1)(a)(b) To seek a review of health needs 04/02/08 for one person who uses the DS0000020833.V340508.R01.S.doc Version 5.2 Page 27 Bealey`s Lane Residential Home service to ensure mental health needs have been addressed. 6 YA20 13 (2) Where medication is administered to people who use the service, staff need to follow robust procedures, using the Medication Administration Record to check the medicines and sign the sheets only after medicines have been administered. 22/01/08 7 YA24 23 (2)(b) Paintwork in the home needs to 30/03/08 be redecorated to a good standard to improve the standard of accommodation in the home for people who use the service and as such address the sticky paint. The paving slabs to the front and rear of the home need to be addressed to ensure that people who use the service are not placed at risk from tripping over looses and raised slabs. People who use the service must have access to all parts of the home as detailed within the Statement of Purpose and contract. The first floor bathroom needs to be reviewed to ensure the room meets the needs of people who use the service. Where people have been identified as requiring sluicing equipment to meet their needs, suitable washing equipment with a sluice facility must be provided to meet infection control standards. 21/03/08 8 YA24 13 (4) 9 YA27 4 (1) 21/02/08 10 YA30 23 (2)(k) 21/03/08 11 YA33 12 (1)(a)(b) To review the staffing and 28/02/08 support provided in the home, to DS0000020833.V340508.R01.S.doc Version 5.2 Page 28 Bealey`s Lane Residential Home reflect the support of all people who use the service and in relation to lifestyle and activities and agreed behavioural support. 12 YA30 23 (5) To consult with environmental Health and arrange for an inspection of premises to check suitable standards are maintained to ensure people are not placed at risk. Training for the Mental Capacity Act needs to be delivered to all staff working with people who use the service and supporting people with their plan of care, to ensure individuals are suitably assessed and records reflect the changes brought about by the Act. The entrance to the home is to be fitted with suitable locks as recommended by the Fire Department to ensure safe evacuation of people who use the service. 29/02/08 13 YA35 18 (1)(c)(i) 21/03/08 14 YA42 23 (4)(c) 28/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA6 YA23 YA39 Good Practice Recommendations To review the current care plans to contain only important daily information and support required For people who use the service to open a bank account to maximise their finances To complete a developmental plan based upon the finding of the service Quality Assurance Audit and distribute to people who use the service and stakeholders. DS0000020833.V340508.R01.S.doc Version 5.2 Page 29 Bealey`s Lane Residential Home Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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