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Inspection on 22/07/08 for Bealey`s Lane Residential Home

Also see our care home review for Bealey`s Lane Residential Home for more information

This inspection was carried out on 22nd July 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service provides information for service users, and seeks the view of families and supporters about the service. It ensures that service users needs are assessed and that the care plans reflect the needs of each individual. Service users are supported to maintain close relationships with family and friends and have been supported by the home to have a holiday day trips. The systems in place for the safe management and administration of medication are good. And service users are supported to access health services and receive treatment as required. 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 are provided in sufficient numbers. The manager has the skills and experience to manage the service and has a good understanding of what she needs to do to ensure that the service continually improves and develops.

What has improved since the last inspection?

Policies and procedures and the Statement of Purpose and service user guide have been reviewed. Plans of care have been developed to encompass person centred thinking and are reviewed regularly. Redecoration of the service continues, the front driveway has been resurfaced and a new kitchen floor ordered. The service provider has developed a Quality assurance system that includes seeking the views of people who use the service, professionals and family members.

CARE HOME ADULTS 18-65 Bealey`s Lane Residential Home 1 Bealey`s Lane Bloxwich Walsall West Midlands WS3 2JT Lead Inspector Wendy Jones Key Unannounced Inspection 22nd July 2008 10:30 Bealey`s Lane Residential Home DS0000020833.V368902.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.V368902.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.V368902.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.V368902.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 21st January 2008 Date of last inspection 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 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 Service User Guide recorded that the weekly fee level for the home was between £1,251 and £2523, including £300 towards the cost of an annual holiday. Bealey`s Lane Residential Home DS0000020833.V368902.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 was a key inspection site visit of this service undertaken on 22 July 2008 and included formal feedback to the manager. In total the visit took approximately 07:00 hours. The purpose of this visit was to assess the services performance and to establish if it provides positive outcomes for the people who live there. The visit included checking that any requirements and recommendations of the previous inspection visit of 21/01/08 have been acted upon; looking at information the service provides for prospective residents, their carers and any professionals; looking at information that the service provides to people who use the service to ensure that they understand the terms and conditions under which they have agreed to live at the home and the fees they should pay. Other information checked included assessments and care records, health and medication records; activity and records relating to the menu’s, finances, staff training and recruitment, complaints and compliments, fire safety and health and safety checks. The manager and staff were spoken to during the site visit, discussion with service users was restricted due to communication difficulties, but service users were observed in their home and their key workers were spoken to. Before the visit began, the service provided it’s own assessment of its performance, in the form of an Annual Quality Assurance Assessment (AQAA). Surveys were sent to the service to be distributed to all service users and their relatives, 10 staff and 10 professionals that have involvement in the service. We have received 1 relative and 1 survey from a pharmacist. People who use the service are referred to as service users throughout this report. As a results of this visit 3 requirements and 14 recommendations have been made and the service will be asked to provide an improvement plan to show us what they have done to address the areas where they need to do further work for the benefit of service users. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The service needs to consider how it can more effectively ensure that service users are involved in day-to-day decision-making and have access to leisure activities of their choice. It must evidence that any decisions are made in the best interests of service users and are not staff led. Where professional advice has been sought to provide staff with guidance about the management of behaviour, the service needs to ensure that the advice is followed for the benefit of service users. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 7 The service should ensure that training is up to date this particularly relates to the protection of vulnerable adults, the Mental Capacity Act, manual handling and basic food hygiene. Values and attitudes and person centred training should also be considered. Staff should also receive regular supervision sessions and the organisation must provide the manager with on-going support. The environment should be developed to provide a more comfortable and homely appearance, furniture should be replaced where it is damaged or broken and any outstanding decoration completed. Bedrooms should be decorated and service users supported to personalise them. The medication cupboard also needs to be replaced. The service needs to contact the fire authority for advice about fire drills and evacuations. 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.V368902.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.V368902.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): Quality in this outcome area is (good) This judgement has been made using available evidence including a visit to this service. People who may use the service can be sure that they will receive information about the service so that they can be sure it can meet their needs. They also can be confident that their needs will be assessed. EVIDENCE: The service has a Statement of Purpose and service user guide. The service tells us they could improve in this area by producing this type of documentation in a user-friendly format. From observation the information also needs to be updated in some areas, including our contact details and information about us. It was noted that the Statement of Purpose states that the service will offer respite care; this was discussed with the manager. The provision of respite care is not compatible with a service that provides a home for life for the service users and should be reviewed. Since the last inspection site visit each service user has received a contract stipulating the term and conditions of their residency. The service told us, “A full needs assessment is carried out on the initial meeting, by the home manager to ensure that the home can meet the all of the needs of the individual. The service user, their families and social worker etc are invited to look around the home to see if they like the home and are encouraged to raise and discuss any concerns or issues they may have. The Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 10 service user is introduced to staff on duty and other service users who live in the home. The service user is invited to carry out a series of visits which include a over night stay and a weekend stay to see if they like the home and to see if the new service users fits in with the other services users in the home.” One relative told us, “We are supplied in general with good information about our relative’s care.” The service has also sent out surveys they received 6 responses from 11 sent, 5 of the responses were from professionals, 1 was from a relative. Responses were positive to the questions asked. All stated that they were made to feel welcome when visiting Bealeys Lane and all confirmed that they receive relevant information. Bealey`s Lane Residential Home DS0000020833.V368902.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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that there are support plans in place that are reviewed regularly, but cannot always be sure that they are consulted about them or that they are followed. This places them at risk. EVIDENCE: The service told us, “We have up to date individual support plans and risk assessments, that are person centred and include goals and needs for each service user, these have been explained to each service user in a level of communication understood by to them. Each service users social worker and families/friends have reviewed them at each review. The support plans include the level of support each service user needs, as they are unable to manage their own medication or finances so there are policeis and procedures in place to ensure that these tasks are carried out correctly. Service users and families are involved in writing the plan where possible if not they are explained to the service user.” Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 12 We looked at sample of care records and saw that the manager has worked hard to ensure that they are up to date. The new format for support plans is person centred and reported to be much better than at the previous inspection, providing staff with a better account of the assistance each individual needs. There is also evidence of reviews and that staff have read the support plans. We spoke to 2 staff about the service users they are key worker for. Both gave accurate accounts of service users needs and how they are to be met. Both showed an understanding of the principles of person centred thinking, but there is evidence that this has not always been put into practice. In addition consultation and service user involvement is not always evident. Staff cited difficulties with communication and understanding as a barrier to this. It is of concern that service user may not be consulted at all for this reason. None of the service users have been supported to return our surveys, and while accepting that this is voluntary it is disappointing that service users haven’t been supported to have their say. This was discussed with a member of staff who said, “We didn’t think that it was appropriate for staff to support the service user in this way as staff could influence the responses of the individual.” While accepting this could happen, it is expected that staff will act appropriately and with integrity. At the last inspection there was concern that the service was not meeting the needs of one service user, and it was advised that behavioural services should be contacted to offer support and to assist with the development of behavioural management strategies. This has taken place and there are clear guidelines for staff to follow. Unfortunately these guidelines are not always being followed and an example occurred on the day of the visit. Staff gave indications that they are not always confident that the strategies will be effective and did not always follow the guidance properly. Bealey`s Lane Residential Home DS0000020833.V368902.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): Quality in this outcome area is (poor) This judgement has been made using available evidence including a visit to this service. People who use the service cannot be confident that they will have the opportunity to be engaged in activities of their choice or that their cultural backgrounds are respected. EVIDENCE: The service told us, “Activities and outings are offered daily and are carried out. Staff provide support to all service users so that they are able to access the community, we also have our own mini bus and driver to assist us to access all areas of the community. Staff promote integration in the community and regularly attend public events for example carnivals. Service users have the opportunity to attend any community event and are keep up to date with upcoming events despite their disability.” The manager said that one service user has had an interview for a college course and it is hoped that if accepted he would attend in September. She identified difficulty finding suitable occupational or educational opportunities Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 14 A relative said, “ We think more activities should be planned to occupy our relative and feel they would not be so anxious if this happened.” From a sample of activity records over a period of a month there is evidence that the individual had been out of the home on a few occasions; the records show that during June this individual went shopping on 5 occasions, on a mini bus outing on two occasions, a day trip on one occasion and a trip to the garden centre on another occasion. The service user had not been involved or had the opportunity to participate in the preferred activities identified in their support plans, for example, bowling, the cinema, swimming, the theatre and therapy sessions. This supports the view that although support plans are in place they are not being followed. During this visit, service users were not actively engaged in any activity, one spent long periods of time sitting in the lounge next to a box of toys, another spent long periods of time lying on the sofa or in the bedroom and a third spent time in the bedroom or wandering without purpose in the home. Staff were observed to interact with service users but not actively engage them in meaningful activity. The service told us, “All service users wishes, race and cultural needs are respected at all times.” The manager said, “ although we have two service users who are from a minority ethnic background, they do not have any specific needs, if they did we would respect this. We do offer individuals a choice of meal that reflects their background on occasions.” It is of concern that the service has stated that service users may not be able to make informed decisions in relation to some aspects of their lives but appear to indicate in this instance they have, this is confusing to us. We recommend this matter is given further thought and the service more actively promotes the cultural needs of service users. Two service users have been on a short break away; another service user has been out on day trips and a fourth has trips planned. The manager confirmed that the allocated holiday money of £300 that forms part of the contract has been used to fund this. The service told us, “Letters are sent to service users families monthly by individuals link workers to keep their families updated on their family members, phone contact and visits are encouraged at all times.” A relative said, “ We have regular letters, photos and phone calls.” We saw that the menu is displayed on the notice board and photographs of the meals to be served are used to support individuals to make a choice. We did not see a choice of meal that reflects the cultural background of the two services previously discussed. Staff reported that meals are flexible and people are able to choose what they want to eat at each mealtime. We Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 15 observed that the kitchen is locked and service users do not have access or have the opportunity to be involved in meal preparation. We understand that the service employs a cook. It’s a shame that the service users are not encouraged to be actively involved in food preparation. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 16 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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use services have access to health both within the home and the community. Medication administration practices are now robust, but the lack of staff commitment to follow behavioural specialists advice potentially puts people at risk. EVIDENCE: The service told us, “Service users privacy and dignity is respected at all times, personal support is provided in private whilst respecting service users wishes. Initial health profiles and health action plans are in place for each service user.” Health records show that annual health and medication checks are undertaken, information is available regarding specific health needs of service users. Health action plans have been introduced. A requirement of the last inspection regarding the review of the health needs of one service user has been complied with. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 17 A behavioural specialist have been involved to offer support and advice to the staff team around behavioural management for one service user, but as referred to in the other sections of this report there is some evidence from observation and discussion during this visit that the advice is not always followed. Medication practice has changed since the last inspection visit and now delivery of medication to the individual is safer. The procedure is that medication is taken from a locked cupboard and transferred to a lockable box and then taken by the member of staff responsible to each service user to whom medication is to be administered. A second member of staff observes the procedure and they also sign the medication administration record to confirm correct administration has taken place. The records show that an individual authorisation to administer medication form has been competed for each service user. Photographs of service users are on file and protocols for the administration of medication have been produced, it’s recommended that these be agreed with the prescribing doctor or consultant. Staff have received training in the administration of medication and have been assessed as competent to do so. The service told us that is intends to assess staff competency to administer medication at regular intervals. The pharmacist said that the service always responds appropriately to any advice and queries and manages service users medication appropriately. There have been changes to the rules in relation to medication storage facilities since the last inspection visit; the manager said that they have ordered a new medication cupboard that complies with current guidance. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service have access to a complaints procedure that is easy to understand. They cannot be confident that staff have up to date knowledge of safeguarding and the action they should take to protect service users from abuse. EVIDENCE: The service told us, “We have copies of the complaints procedure in various formats, these are explained to the service users, copies are displayed, copies are sent to families and relevant parties. Views and concerns are listened to, complaints are taken seriously and dealt with in accordance to the policy in place. We have a complaints folder where complaints are logged and reviewed every three months by the manager.” A relative said, “I know how to make a complaint, and the service has always responded when I have raised concerns about my relative’s care.” A professional said, “ The service has always responded appropriately if concerns have been identified.” A Complaints procedure is on display in the home and is included in the service user guide and statement of purpose. The format is user friendly and easy to understand. We have not received a complaint about this service and the service told us they haven’t received one. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 19 One staff member confirmed that she had received abuse training, records show that all staff have received this training but it was sometime ago 20042005, its recommended that this training is repeated. This will ensure that staff have up to date information, understand current guidelines and know how to keep people safe. In January a safeguarding referral was made to the local authority and was investigated. The conclusion was that there was insufficient evidence to support the allegations. It should be noted that the service co-operated fully with those enquiries. We are also aware of another allegation that has also been referred under safeguarding procedures with similar allegations made. This is currently under investigation. The manager was told about this during the visit and the records the service has that may be relevant to this matter have been made available. None of the service users manage their own money; records show that service users finances are checked 3 times per day, records show running totals are maintained. These were checked against actual amounts of money and found to be accurate. It is noted that some service users have amounts of cash exceeding £250. This conflicts with the limits as stated in the company insurance policy. This practice does not safeguard service users finances. None of the current service users has been supported to have a bank or saving account, this is not satisfactory and is not in the best interest of service users, The manager told us that the service has now received a training package relating to the Mental Capacity Act, the pack includes a DVD and work booklet and all staff are aware of the need for this training. It has not yet been delivered. This issue was a requirement of the last inspection report, but due to changes in our guidance we have not carried this forward as a requirement this time. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 20 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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service do not enjoy a comfortable or well-maintained environment, despite action having been taken to improve the home. This is not acceptable and doesn’t promote the rights of service users or evidence that they are valued. EVIDENCE: The home is a detached property in an established residential area. The appearance from the exterior is of a well maintained home. A requirement at the last inspection about the unsafe drive way has been addressed and the area has been resurfaced. On entering the building the appearance does not reflect the outside, the décor is stark and does not present as homely. At the last inspection a requirement was made that the service needed to address environmental issues. Some of these have been dealt with and work was being undertaken during the visit to Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 21 resolve the other matters. However significant work and thought should be given to the general appearance of the home. The service told us, “we have improved by implementing new maintenance logs, now have a maintenance man who visits the home once a week so maintenance does not build up. We have decorated one service users bedrooms to a colour of his choice. We have supported service users to personalize their bedrooms.” We saw 2 bedrooms one had been recently decorated and was neat and tidy. The individual had family photographs on display. The other was poorly maintained and the décor did not reflect the age of the occupant. It was also disappointing to note that there wasn’t a mirror in the room. Our general observations are that in the lounge, furniture is positioned around the edge of the room and there is every little to make it appear homely, the sofas are in a leather washable material that have been damaged and require replacement. A small basic looking table and chair is located in this room for one individual to eat at. There are no curtains at the window of the home, staff said this was due to the behaviour of a service user, some stencil work has been done on individual panes of glass to try to obscure the view from the lane, but there is clearly an issue of privacy. The main dining room is also the conservatory. The table has 4 chairs, which do not match and has been identified in the last provider report on the home as requiring replacement for safety reasons. The dining area is inadequate and does not provide enough space for all service users and their supporters to dine comfortably together. It is accepted that behavioural issues mean that service users often have their meals separately. The service has a ground floor and first floor bathroom; the first floor room has been redecorated as requested at the last inspection. The manager said service users now use it, although due to the behaviour of service users remains locked. The garden is private and well maintained, a large trampoline with safety surround is provided for those service users who enjoy this activity. There are plans to extend the fencing to ensure the garden is not overlooked. We spoke to a maintenance person who reported that he was working in the home for an extended period of time until all the work he had been asked to do was completed; this included sanding down all of the paintwork and re painting. At the last key inspection 3 environmental requirements were made, two have been completed and the third was being acted upon during this visit. The workman confirmed that he had been asked to remain at the home to complete all the outstanding work. Suitable laundry facilities are in place and the home appeared to be clean. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 22 Bealey`s Lane Residential Home DS0000020833.V368902.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that staff are available in sufficient numbers to meet their needs but cannot be sure that staff have the necessary skills, training or support to do so. This impacts on their quality of life. EVIDENCE: Staff rota’s show that 4 staff are usually deployed for an early shift and usually 3-4 for the afternoon and evening shift. The manager’s hours are usually supernumerary to these. The service also employs a cook between the hours of 11am-14.00 for five days per week and a driver, 9am-15.00 for five days per week. Two waking staff are on duty each night. The manager told us that the service does not have any staff vacancies, two staff are currently on maternity leave, but their hours have been covered. A new night member of staff has recently been recruited and a senior care position filled, both new recruits are awaiting suitable pre employment checks. We looked at 2 recruitment files, both had relevant documentation including application forms, two written references, Criminal Records Bureau checks Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 24 (CRB). Checks of the Protection of Vulnerable Adults list, (POVA) are also recorded. Staff meetings records show meetings have been held regularly held on 10/04/08, 07/05/08 and 18/06/08. But records of staff supervision show significant deficits in terms of frequency. This was discussed with both the manager and deputy. Staff said that mandatory training is up to date; records show that some updates are needed in areas such as moving and handling, safeguarding and basic food hygiene. The manager told us that the service has a training pack for Mental Capacity Act training but this has not yet been delivered to staff. Values based training and person centred planning training would be of benefit to staff. The number of staff who have are trained to National Vocational Qualification (NVQ) level 2 is higher than the recommended minimum. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 25 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): Quality in this outcome area is (adequate) This judgement has been made using available evidence including a visit to this service. People who use the service can be confident that the manager has the experience and training to manage the service and she has a clear idea of how the service can be improved. But person centred thinking is not put into practice and affects the quality of life of service users. EVIDENCE: The manager has returned to work following an extended period of leave. She has the necessary experience and qualifications to manage the service. On the day of this visit she was not scheduled to be on duty, but came in to the home to assist with the inspection process. We are grateful for the commitment shown by her. The manager completed the Annual Quality Assurance Audit (AQAA) for us prior to inspection of the home. All sections of the AQAA were completed and Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 26 the information gives a picture of the current situation within the service. Information in the AQAA informs us that servicing of equipment is up to date, and policies and procedures have been reviewed. We saw that records in home indicate that staff have not been involved in regular fire drills or evacuations this is of concern. We have referred this to the fire safety officer. The organisation is required to visit the service at least monthly and to produce a report on the conduct of the service. These visits should be unannounced. The records show that these visits have not always taken place or when they have been undertaken have not been effective. This has left service users at risk. It is also disappointing to note that the manager has not received on going support in terms of supervision. The service told us, “There is a quality assurance system in place to ensure we continually improve the service we offer. Satisfaction surveys are sent out to all families, friends and professionals involved in our care settings, once returned the results are analysed and an action plan is drawn up. A copy of the analysis and the action plan is sent out to all who received a questionnaire even if they did not return their copy. Our service users have difficulty completing surveys and questionnaires so we use our knowledge and observation to judge service users satisfaction levels.” This was confirmed from the records available to us. The service has worked hard to address all the requirements and recommendations of the last key inspection visit, but there continue to be a number of areas that need further work. Areas where the service must improve are identified in the Lifestyle, Environment, Complaints and Protection and Staffing sections of this report. As a result of this visit we will be asking the service to complete an improvement plan to confirm that they have acted upon the issues we have identified. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 27 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 3 2 2 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 2 ENVIRONMENT Standard No Score 24 2 25 3 26 2 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 x 36 1 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 2 3 X LIFESTYLES Standard No Score 11 X 12 1 13 1 14 1 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 3 X 3 X 3 X X 2 2 Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? NO 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 12 Requirement The service must ensure that behavioural care plans are followed to be confident that people who use the service are not put at risk. The service must consult with the fire authority about making adequate arrangements for fire drills. To ensure that all staff know what to do in the event of the fire alarm sounding. Timescale for action 22/09/08 2. YA42 23(4)(e) 22/08/08 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. Refer to Standard YA2 YA14 Good Practice Recommendations The provision of respite care should be reviewed. People who use the service should be supported to have DS0000020833.V368902.R01.S.doc Version 5.2 Page 29 Bealey`s Lane Residential Home 3. YA1 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. YA1 YA23 YA35 YA24 YA24 YA26 YA42 YA20 YA7 YA36 YA36 YA32 YA43 access to leisure and recreational opportunities that have been listed in their plans of care. The Service User Guide and Statement of Purpose should be reviewed to ensure that the information it contains is up to date, this ensure that people who may use or do use the service receive accurate information. The service should ensure that all relevant information is produced in a format that service users can more easily understand. The service should support people who use the service to open a bank account to maximise their finances Mental Capacity training should be provided to all staff. 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 provide service users with window covering, therefore promoting their privacy. The service should provide a mirror in the bedroom for the service user identified. The service should ensure that all mandatory training is up to date this includes manual handling. The service should provide a suitable storage facility for medication. The service should ensure that a full account has been taken of the cultural background of service users so that they can make a choice. 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 should provide staff with values and person centred training. 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. Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West Midlands West Midlands Regional Contact Team 3rd Floor 77 Paradise Circus Queensway Birmingham, B1 2DT National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Bealey`s Lane Residential Home DS0000020833.V368902.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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