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Inspection on 05/05/05 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 5th May 2005.

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 43 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

When asked what`s the best thing about Bealeys Lane one member of staff stated, "even though the service users have challenging behaviours we don`t restrict them" and another stated, "service users have such freedom of choices". The inspector found that these statements reflect practices within the home, where service users are enabled to make choices within risk managed frameworks. Staff should be congratulated for their efforts to ensure positive relationships are maintained between themselves and the people living at the home despite service users having a range of communication difficulties. Throughout the visit the inspector witnessed staff making eye contact, looking at facial gestures and body language in order that service users wishes could be obtained. It was also pleasing to see staff giving service users physical contact such as holding hands and stroking cheeks, understanding that this contact was both reassuring and comforting to the people concerned. This practice was reinforced by a member of staff who stated, "if someone seems unhappy just a hug or a touch on the hand can make everything seem better, it`s the same for all of us, why should it be any different for the people here".

What has improved since the last inspection?

Since the last inspection many staff have undertaken lots of training courses that help them to care for everyone living at the home. All the staff said that these had helped them to do their job better, especially the Crisis Prevention Intervention training which has helped them care for service users when they get angry or upset. It was also pleasing to find that staff recruitment and selection records were now in place as previously these had not met legal requirements and did not ensure service users were protected.

What the care home could do better:

It was the general view of staff that, "the decoration lets the home down". Many parts of the home are looking worn and require attention to make sure people live in a safe, comfortable and homely environment. The inspector could find no evidence of future planning that ensures the building is maintained to an acceptable level. Every service user file examined by the inspector had missing health related information. Health care monitoring is poor and must be improved quickly to ensure that people living at the home get the individual care they need in a timely fashion. A staff training and development programme must be put into place that demonstrates staff have the qualifications needed to meet the needs of service users. This must include maintaining certificates and completing an assessment that shows how staff training benefits service users.

CARE HOME ADULTS 18-65 Bealeys Lane Residential Home 1 Bealeys Lane Bloxwich, Walsall West Midlands. WS3 2JT Lead Inspector Lesley Webb Unannounced 5 May 2005 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 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 Stationary 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. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bealeys Lane Residential Home Address 1 Bealeys Lane Bloxwich Walsall West Midlands. WS3 2JT 01922 492285 01902 421941 Telephone number Fax number Email 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 Ltd. Miss Vicky Hill (Acting) Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 12th November 2004 Brief Description of the Service: Bealeys Lane is a five-bedded care home for individuals with severe learning disabilities and challenging behaviour. It is owned by Swan Village Care Services Limited which was established in 1988 to offer tailor-made services for adults with learning disabilities both in residential and day care settings. The home is located near to the centre of Bloxwich, opposite the park and close to shops, pubs and other amenities. The home was opened in 1995, originally being a residential dwelling, domestic in nature that has been converted for its present use. All the homes bedrooms are single without ensuite facilities. It has a bathroom and toilet on both floors, a large lounge, conservatory, kitchen, office and utility room. The home has parking facilities to the front of the building and a private garden to the rear with a patio area. The home also provides transport in the form of a mini bus with tail lift. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspector arrived unannounced at the home at 7.30am and stayed until 3.40pm. On arrival four service users were at various stages of preparing for the day, some having breakfast and others receiving assistance from staff to get dressed. The people who live at Bealeys Lane have severe learning difficulties and/or challenging behaviours and/or communication difficulties resulting in the inspector being unable to hold interviews with them. Therefore she spent about one and half hours sitting in the lounge observing routines and practices between individuals and staff in an attempt to judge individuals satisfaction with the care they receive. Once the majority of service users had left the home to attend day services the inspector then formally interviewed four staff, spoke with the Acting Manager, toured the building and looked at records before giving feedback about the inspection. Since the last inspection in November 2004 the Registered Manager has left and an Acting Manager appointed who previously managed another home owned by Swan Village Care Services Limited. By the end of the visit the inspector was satisfied that, in general, the levels of care provided were satisfactory and the change in management had not impacted negatively on service provision. The inspector was made to feel very welcome and would like to thank service users and staff for their assistance and co-operation during the visit. What the service does well: When asked what’s the best thing about Bealeys Lane one member of staff stated, “even though the service users have challenging behaviours we don’t restrict them” and another stated, “service users have such freedom of choices”. The inspector found that these statements reflect practices within the home, where service users are enabled to make choices within risk managed frameworks. Staff should be congratulated for their efforts to ensure positive relationships are maintained between themselves and the people living at the home despite service users having a range of communication difficulties. Throughout the visit the inspector witnessed staff making eye contact, looking at facial gestures and body language in order that service users wishes could be obtained. It was also pleasing to see staff giving service users physical contact Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 6 such as holding hands and stroking cheeks, understanding that this contact was both reassuring and comforting to the people concerned. This practice was reinforced by a member of staff who stated, “if someone seems unhappy just a hug or a touch on the hand can make everything seem better, it’s the same for all of us, why should it be any different for the people here”. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1 and 5. Information is available about the home, however it is not in a format suitable for intended users. EVIDENCE: The Statement of Purpose and other information about the home are displayed at the entrance to the home. The service user guide is still not being provided in a format suitable for the people it is intended for and does not contain all required information as previously identified in other inspections. Each service user has now been given a contract detailing terms and conditions of residency however only one has been signed by a representative of the service user despite this being identified in previous inspections. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 and 9. Care plans must be developed and contain conprehensive information relating to forms of communication in order to provide staff with the information they need to support service users. Staff respect service users rights to make decisions, and that right is limited only through the risk assessment process. EVIDENCE: Four members of staff were interviewed and all but one (who had not been working at the home long) was able to give examples of aims/goals contained within service user care plans. These included shopping skills, behaviour management and increased communication. The inspector verified these examples as accurate when checking the relevant care plans. Although many of the service users living at the home have challenging behaviours no staff gave detailed explanations of systems in place to manage behaviour. The inspector was concerned about this until staff explained that they did not see individuals as having ‘challenging behaviour’ but that different people had different needs and that is was the responsibility of staff to understand those needs and support individuals in the way best suited to them. Staff also stated Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 11 that monthly key worker meetings occur with service users if they wish to be present, along with six monthly care plan reviews, however records did not substantiate six monthly reviews occurring for everyone. When looking at the care plan of one individual the inspector found that it stated a referral to the speech and language department should be made, however no evidence of this occurring could be found. In addition to care plans several files also contained ‘About me’ Person Centred Plans. The inspector found these to be very basic with no evidence that service users had been involved in their compilation. The manager confirmed that no one had undertaken training in either communication or person centred planning. The inspector found an abundance of detailed risk assessments for all service users detailing assessments for a variety of areas including aggression, communication, self injury and vulnerability, all of which had been reviewed and signed by the manager. When the inspector asked staff if service users are able to take risks all confirmed that they are, but where assessments have demonstrated risk levels to be high and potentially dangerous structures are put in place to attempt to minimise this. For example one service user can make breakfast for themselves but requires staff assistance due to not understanding the dangers of sharp objects and heat from the cooker. One member of staff who was interviewed also recognised that as staff they can advise service users of risk levels but they have the right to ignore this if they chose. The member of staff stated, “one service user has mobility problems where he is at risk of falling when walking long distances. We offer him a wheelchair and explain the risk but sometimes he chooses to ignore this and we cannot insist”. The inspector was also pleased to note that many staff at the home are due to undertake formal risk assessment training in one weeks time with a qualified person. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 13, 14, 15 and 17. Social activities and meals are both well managed, creative and provide daily variation and interest for people living in the home. EVIDENCE: Records and conversations with staff confirmed that service users take part in activities in the local community including using visits to local shops, pubs, garden centres, discos and swimming. Since the last inspection the home has organised its own disco that is held every fortnight where anyone from the community can attend. The proceeds from this event are then used for the service users at Bealeys Lane to go on daytrips. During the inspection staff were observed talking to service users about a disco they would be attending that evening, with service users appearing very happy and excited about this event. During the inspection the inspector witnessed staff participating in board games with service users, playing football and watching television, however when looking at activity records it was found that staff had not been Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 13 recording in-house activities. The inspector instructed that all activities must be recorded in order to demonstrate that service users live full and active lives. Staff were asked how service users are helped to maintain family links with a variety of replies including “one service users mom phones every week. Due to her son not being able to talk we inform her first of what her son has done, then she talks to him about these things” and “it depends on the family, some phone, others visit or we take the service users to visit them”. The inspector was also informed that one key worker regularly writes letters informing a family of events concerning their son due to the family living a distance away. The inspector saw a letter of gratitude from the family expressing their thanks for this contact. The inspector recommended that this form of contact be implemented for all families due to the communication difficulties service users have living at the home. A number of service users were seen at breakfast time, all of whom appeared to enjoy this meal. Each person was assisted by members of staff, depending on their needs, in a discreet and sensitive manner. The inspector was pleased to observe staff looking for signs that service users had finished their meal, offering further time to eat and not assuming someone had finished just because they had put their spoon or cup down. Staff that were interviewed stated that “we look for facial gestures or body language to let us know if someone likes a certain food or not and change the menu if it appears they don’t”. Although there is a dining area service users were observed sitting in various locations of their choice throughout the home when eating, with this choice respected by staff. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20. The staff have knowledge of the service users support needs that could be enhanced by training specifically aimed at individual communication needs. Further work must be undertaken to ensure all service users health needs are assessed, monitored, recorded and met in full. EVIDENCE: Staff were honest with their responses when asked if service users are given personal support in the way they want and require, stating that this can sometimes be difficult to know for sure due to communication difficulties of some people living at the home. Staff confirmed that they look for facial gestures and body language as signs that individuals are in agreement with the care being given, but also stated that they had not received communication training that was specific to individuals living at the home. When the inspector sat observing practices service users appeared happy with the support being given, smiling and volunteering to go with staff when personal care was required. All staff demonstrated knowledge of each individuals needs. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 15 Staff confirmed that some service users require wheelchairs when out in the community. When looking at records for these individuals the inspector could find no evidence that an assessment had taken place for one person and no one at the home could confirm if this had occurred. In addition to this the wheelchair was found to have no safety strap and a faulty brake. Due to this an Immediate Requirement Notice was issued instructing that the wheelchair be removed from use. When staff were asked how service users physical needs are met the general reply was by ensuring their care plans and health records are maintained. It was therefore disappointing to find that service users Health Assessments had still not been completed in full and with enough detail, despite being identified as a Requirement in the previous inspection. In addition to this not all service users records demonstrated that they are offered minimum annual health checks for vision, chiropody and hearing. Discussions with staff suggested that some health needs are being addressed even though there is a lack of detailed recording. This approach is dependant on staff memory and residents are at risk of not having their needs met in full if these informal systems break down. In general the policies and practices relating to the administration, recording and storing of medication comply with legislation. The inspector did however find that prescribed creams were still not being appropriately labelled despite this being identified in the previous inspection. It was also recommended that the home arrange for the supplying pharmacist to carry out regular medication audits as records indicated that this had last occurred February 2004. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. Recordings systems must be improved for complaints to ensure the protection of vulnerable adults. Staff demonstrated awareness of their responsibilities in relation to supporting service users to complain and acting on behalf of those with communication difficulties. EVIDENCE: When asking staff how they make sure that service users complaints are dealt with everyone replied, “speak to the seniors or manager”. In addition to this others stated that staff must act as advocates for service users, reassure them and always make sure complaints are dealt with. The inspector found that each service users file contained the homes complaints procedure in large print and picture format that also had been signed by the manager stating that the procedure had been explained to the individual. Since the last inspection two complaints have been received directly to the Commission for Social Care Inspection both of which were partly upheld. When checking the complaints log neither of these had been recorded at the home. All staff interviewed confirmed that they had undertaken Crisis Prevention Intervention training, however certificates were not available to validate this. Staff demonstrated awareness and knowledge of adult protection to the inspector. When asked how they ensure service users are protected from abuse staff replied, “ be vigilant, look for changes in mood, behaviour, marks on the body”. Also staff confirmed that suspicions should always be reported to the manager. The inspector was also shown confirmation that staff will be attending Abuse Awareness training in two weeks time. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 26,27, 28, 29 and 30. The standard of the decor within this home is poor with little evidence of improvement through maintenance or future planning. The home does not, therefore, present as a homely and comfortable environment for service users. EVIDENCE: Since the last inspection no evidence of redecoration of any parts of the building could be found resulting in parts of the home feeling worn and unsightly. Particular attention must be given to: * Carpets throughout the home including the lounge, hallways and stairs that are worn and stained. * The laundry room appeared to have damp on the walls and ceiling resulting in the paint peeling, also the room was very dusty and the laundry baskets had no lids. A sluicing facility must also be provided to meet service users continence needs. * The cupboard doors in the passageway by the kitchen were broken. * The flooring in the kitchen requires attention as it is uneven where the freezer is located; also there are two floor tiles that require replacing. The Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 18 inspector also noted that a full set of colour coded chopping boards was required. * Paintwork throughout the home on doors and woodwork was chipped and unsightly. * The downstairs bathroom requires refurbishing as tiles were coming away from the wall around the bath, paintwork stained and no fitments such as a blind at the window resulted in this facility feeling uninviting and worn. * The walls in the lounge require painting as many areas were stained. Also the easy chair used by ‘S’ must be cleaned or replaced if the stains cannot be removed. * Much of the bedding that was seen by the inspector looked worn and thin and must be replaced. * ‘J’ requires the labels removing from the wardrobes and a new bed base due to the one in use being broken and sagging in the middle. * All fire hydrants must be fitted to the walls. * Garden furniture must be provided appropriate to the needs of the service users. The inspector was informed that the home was hoping to have a BBQ this weekend, however only three plastic garden chairs were available for use. An Immediate Requirement Notice was also issued due to the missing floor tiles in the hallway which posed imminent risk to service users. Many of the staff that were interviewed confirmed that the environment could be improved but recognised that this needed approval for funding from the registered providers. Comments such as “the environment lets the home down” and “with a few alterations to the decoration this could be a nice home” were typical of those made regarding the building. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 19 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 34, 35 and 36. The staff have a good understanding of the service users needs. Since the last inspection the standard of vetting and recruitment practices has improved. Some progress has been made in relation to training and development, further work is still required to ensure staff have the appropriate skills and qualification to meet the needs of service users. EVIDENCE: Many of the staff that work at the home have done so for several years, building relationships with service users appropriate to gender, age and personal interests. Staff profiles are completed that detail competencies, skills and experience. The inspector found that these demonstrated that the staff group is made up of individuals from various backgrounds, with differing skills and experiences that complement the service user group living at the home. This was further confirmed within interviews with staff, all of which were able to give detailed accounts of the needs of service users and how they support them to meet those needs from either life skills or knowledge gained through further education they have undertaken such as Learning Disability Award Framework accredited training. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 20 Since the last inspection the inspector found that staff records relating to recruitment and selection maintained at the home had improved, with all files sampled containing information required as listed in Schedules 2 and 4 of the Care Homes Regulations 2001. Although the home completes individual staff profiles and a document that lists staff training requirements for the team as a whole, the inspector did not judge this to be sufficient to demonstrate that an assessment had been completed for the staff team as a whole nor did it demonstrate how training would benefit service users. The manager and many of the staff interviewed stated that they have undertaken equal opportunities training since the last inspection, however no certificates were available to verify this. All staff interviewed confirmed that they receive regular supervision commenting that they found it “useful to discuss problem areas”. Staff also confirmed that they receive annual appraisals but records seen by the inspector showed that some were now due for renewal. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 21 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 39. The appropriate leadership, guidance and direction is given to staff to ensure service users receive consistant care. The home does not regularly review aspects of its performance through a good programme of self-review and consultations. EVIDENCE: The registered manager has recently left the home and the acting manager has been in post for approximately three weeks. The inspector could find no evidence of this having a detrimental effect on the running of the home and service provided with all staff stating that “it has helped that the new manager has worked here before and knows many of the staff and service users”. The Commission for Social Care Inspection must receive an application to register the manager. The quality assurance system in still incomplete, with no annual audit and analysis of service users surveys and questionnaires published. The inspector Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 22 found a document titled ‘Audit of quality assurance system’ however found this to be an audit of the homes Statement of Purpose and not the quality assurance system. The inspector questioned how an audit could take place, as presently the quality assurance system has not been completed in full. The lack of appropriate quality monitoring was further reinforced by staff that were interviewed, as none were able to give an example of how quality is monitored. Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 x 2 2 2 2 1 Standard No 11 12 13 14 15 16 17 x x 3 2 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bealeys Lane Residential Home Score 2 2 2 x Standard No 37 38 39 40 41 42 43 Score 2 x 1 x x x x v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 24 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 YA1 Regulation 4 Requirement The service user guide must be developed in a format suitable to the people it is intended for (REQUIREMENT ORIGINALLY MADE JULY 2003) The service user guide must include fees charged, what they cover, and the cost of any extras and information about how to contact local social services and healthcare authorities (REQUIREMENT ORIGINALLY MADE JULY 2003) A representative of the service user must sign the contract on their behalf (REQUIREMENT ORIGINALLY MADE JULY 2002) Care plans must be reviewed with the service user and their representatives at least every six months Person Centred Plans must be completed in detail with the involvement of service users Both in-house and external activities must be recorded in detail The home must be able to demonstrate that a referral to the speech and laungage department for service user J Timescale for action 01/06/05 2. YA1 4 01/06/05 3. YA5 5(1) 01/06/05 4. YA6 15 30/09/05 5. 6. 7. YA6 YA14 YA18 15 16(2) 12(1) 30/09/05 30/09/05 30/09/05 Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 25 has been made 8. YA18 12(1) The home must be able to demonstrate that all service users who use wheelchairs have assessments completed by a qualified person All staff must undertake communication training that is specific to the needs of service users All service user Health Action Assessments must be completed in full (REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) All service users must be offered minimum annual health checks for vision, chiropody and hearing All prescribed medication must be appropriately labelled (REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) A record must be kept of all complaints The home must be able to validate that all staff have undertake Crisis Prevention Intervention training The worn and stained carpets in the lounge, hallways and stairs must be replaced The broken cupboard doors in the passageway by the kitchen must be repaired or replaced The chipped paintwork throughout the home on doors and woodwork requires repairing The stained walls in the lounge require re-decorating The easy chair used by S must be cleaned or replaced if the stains cannot be removed The broken floor tiles in the hallway must be replaced All fire hydrants must be fitted to the walls The labels must be removed 30/09/05 9. YA18 12(1) 30/09/05 10. YA19 12(1) 01/06/05 11. 12. YA19 YA20 12(1) 13(2) 30/09/05 01/06/05 13. 14. YA22 YA23 22(1) 10(1) 30/09/05 30/09/05 15. 16. 17. 18. 19. 20. 21. 22. YA24 YA24 YA24 YA24 YA24 YA24 YA24 YA26 16(1) 16(1) 16(1) 16(1) 16(1) 16(1) 16(1) 16(1) 30/09/05 30/09/05 30/09/05 30/09/05 30/09/05 06/05/05 30/09/05 30/09/05 Page 26 Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 from J wardrobes 23. 24. 25. YA26 YA26 YA27 16(1) 16(1) 16(1) J requires a new bedbase All worn bedding must be replaced The downstairs bathroom requires refurbishing (including replacing loose tiles, painting stained walls and putting a blind at the window) The uneven flooring in the kitchen must be addressed Two floor tiles in the kitchen must be replaced A full set of colour coded chopping boards must be purchased Garden furniture must be provided appropriate to the needs of the service users The faulty wheelchair must be removed The laundry room must be investigated for damp and the appropriate action taken to elimenate it The laundry room walls and ceiling must be decorated and readily cleanable Lids must be provided for the soiled laundry bins The home must have a sluicing facility The home must be able to validate that all staff have undertaken equal opportunities training The home must ensure a training needs assessment is completed for the staff team as a whole, and an impact assessment of all staff development is undertaken to identify the benefits for service users and to inform future planning All staff must receive an annual appriasal The CSCI must receive an 30/09/05 30/09/05 30/09/05 26. 27. 28. 29. 30. 31. YA28 YA28 YA28 YA28 YA29 YA30 16(1) 16(1) 16(1) 16(1) 16(1) 13(3) 30/09/05 30/09/05 30/09/05 30/07/05 Immediate 30/09/05 32. 33. 34. 35. YA30 YA30 YA30 YA35 13(3) 13(3) 13(3) 18(1) 30/09/05 30/09/05 30/09/05 30/09/05 36. YA35 18(1) 30/09/05 37. 38. YA36 YA37 18(2) 9(2) 30/09/05 01/07/05 Page 27 Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 39. YA39 24 40. YA39 24 41. 42. YA39 YA39 24 24 43. YA40 Schedules 1, 4 application to register the manager An internal audit of the quality assurance system must take place annually (REQUIREMENT ORIGINALLY MADE JULY 2003) Service user, families and other professionals surveys/questionnaires must be analysed, with the results published and made available to everyone including the CSCI (REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) The quality assurance system must be implemented in full Action must progress within agreed timescales to implement requirements identified in CSCI inspection reports(REQUIREMENT ORIGINALLY MADE NOVEMBER 2004) The grievance procedure must be developed and include notifying the complainant of the outcome of the investigation in writing(REQUIREMENT ORIGINALLY MADE JULY 2003) 30/09/05 30/09/05 30/09/05 30/09/05 01/07/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA15 YA21 Good Practice Recommendations It is recommended that all keyworkers write to the families of service users on a regular basis to keep them informed of events concerning their relative It is recommended that the manager re-issue the request for families views on service users funeral arrangements, with documentation maintained if they state they do not want to discuss this subject It is recommended that the individual staff training and development assessments (known as profiles within the v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 28 3. YA35 Bealeys Lane Residential Home home) be completed in more detail in respect of developmental requirements that do not require formal training Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 29 Commission for Social Care Inspection West Point Mucklow Office Park Mucklow Hill Halesowen. B62 8DA National Enquiry Line: 0845 015 0120 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 Bealeys Lane Residential Home v224834 e55 s20833 bealeys lane v224834 050505 stage 4.doc Version 1.30 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!