CARE HOME ADULTS 18-65 Beaufort House Chobham Road Knaphill Woking Surrey. GU21 2TD
Lead Inspector Mr.D. Griffiths Unannounced 09-June-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. Beaufort House Version 1.10 Page 3 SERVICE INFORMATION
Name of service Beaufort House Address Chobham Road, Knaphill, Woking, Surrey. GU21 2TD 01483 475536 01483 489604 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) Whitmore Vale Housing Association CRH (PC) 7 Category(ies) of Learning Disability (LD) 7 registration, with number of places Physical Disability (PD) 2 Beaufort House Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: The age/age range of the persons to be accommodated will be: 18 - 65 YEARS. Two of the seven (7) persons accommodated may be within the category PD in addition to being within the category LD. Date of last inspection 14 October 2004 Brief Description of the Service: Beaufort House is part of the Whitemore Vale Housing Association a charitable housing Society. It is situated in a residential area close to the centre of Knaphill Village on the outskirts of Woking. Beaufort House is registered for 7 adult residents with complex daily needs and communication difficulties . The property has been converted from a private residence comprising seven bedrooms. One Bedroom has en suit shower and toilet facilities. There is a kitchen and large through dinning/lounge room. Off street parking is available at the front of the house and residents have the use of a well maintained and securely fenced garden . Beaufort House Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection of two to be undertaken in the Commission for Social Care Inspection Year April 2005 to April 2006. It was an unannounced visit and took place over a period of 6hrs. Lead Inspector Damian Griffiths was assisted throughout the inspection by Heidi Beech, Manager, representing Beaufort House. The management of the home has changed since the last inspection. Heidi Beech is a new Manager and is waiting to be registered with CSCI. A tour of the premises took place and the inspector was able to meet 5 residents, three members of the staff team and a relative of one of the residents. All were happy to contribute to the inspection report. A sample of two resident care plans, three samples of staff records and the homes policies and procedures were also inspected. It is recommended that the reader should also look at the previous report that can be accessed by using the CSCI website details on the last page of this report. The inspectors would like to extend thanks to the service users, management and staff at Beaufort House for their time and hospitality. What the service does well: What has improved since the last inspection?
Beaufort House been able to maintain the high standards recorded from the last inspection. These included meeting the requirements and recommendations that were made. Staff are now involved with regular Beaufort House Version 1.10 Page 6 meetings that are on target to achieve 6 per year and staff also receive regular supervision. The home provides clear written policy and procedural documentation and residents receive and good standard of care plan recording. Staff maintain a good standard of respect for the residents and also a nice sense of humour that is appreciated by the residents. Staff were seen to interact well with the residents throughout the visit. The residents varied and individual needs were seen to be accommodated without fuss or incident. Residents are able to access all day centres and adult education classes regularly. The management are regularly involved with Quality Assurance of the home and produce regular reports to the inspector as required under regulation 26. The residents and their representatives are also involved with regular quality surveys. The management have also produced an annual business plan, as recommended at the last inspection that will add to the overall view of the successful running of this home. The home was able to show that it is providing a learning environment for other health professionals by introducing to the inspector a student nurse on placement. What they could do better:
Beaufort House has produced a clearly written Statement of Purpose that is well presented however lacks clarity and information about how to contact the CSCI. Information about how to provide the residents’ care currently recorded on the care plan would be better placed in the resident’s room. It would ensure staff have access to the information when and where they need it. This may also provide a consistency and increase the potential to review the care plan on a daily basis. The resident’s care plan sampled was without an assessment of needs. The inspector was satisfied that this has been misplaced and the Manager was recommended to provide this at the next inspection. The house laundry room is without an appropriate sluice facility as required. A sluicing facility that is more able to meet the need of the residents now and in the future needs to be installed. The kitchen reported in the last inspection as a recommendation is now a requirement due to the condition of this much used and essential room. The units are in constant need of repair and have suffered in appearance, and pose a potential safety hazard. Beaufort House Version 1.10 Page 7 Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beaufort House Version 1.10 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 Beaufort House Version 1.10 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) 1-5 The additional information required in the Statement of Purpose and the Service Users Guide will complete and provide prospective and existing services users with the means to make an informed choice. EVIDENCE: The Service Users Guide and The Statement of Purpose were without details of the complaints procedure. The Service Users Guide in particular was without any details of the complaints system. This needs to include details of telephone and fax numbers for Commission for Social Care Inspection, the process of the complaint and clearly defined timescales. There will be a requirement for further information needed to be included in the service users guide. To ensure that each resident has available to them the details of the fees being charged and what is not included in standard service charge, actual extras, such as, hairdresser fees or transport cost must be available. Beaufort House Version 1.10 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) 6-10 The care plans are good and clearly include the requirements to provide a detailed record of care need, inform staff of risks and most importantly the best form of communication that is unique to each resident. The care plan would be of greater assistance if it were kept within the resident’s own room. EVIDENCE: Two care plans were inspected. One resident had in place a complete care plan, risk assessment, record of likes and aspirations and also received full support from the local health professional and showed that the home has addressed the mental heath needs of the resident. The original needs assessment was not in place however all the elements of the assessment needs had been adequately covered. The other care plan sampled was complete. Another important feature of the care plans inspected were the attention to communication specific to each resident. It has been recorded and is in use and includes facial movements, the amount of words to be used in each sentence or body language. There were also examples of pictorial explanations made available within the care plan. Beaufort House Version 1.10 Page 11 It was recommended that the elements of the care plan describing the method providing daily personal care would better serve the resident and staff members if kept in then residents own room. All other information could remain in the office in respect confidentiality. Beaufort House Version 1.10 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) 11,12,13,14,15,16 and 17 Each resident has an individualised programme of activities. Residents have the opportunity to interact with other residents and every effort is made to support the residents to stay in touch with their family and to access the local community. EVIDENCE: The residents are helped to attend the PIPS day centre run by Mencap and the local adult education centre where residents are able take advantage of a variety of courses. At home the residents have full access to the house and gardens and are able to use a room that is specifically designed to stimulate or relax the senses and this is also a quiet room always available. Residents were observed to be addressed by their first names and treated with sensitivity and respect at all times. Friends and family were encouraged to come and go as they please and attend functions at the home. The residents have the opportunity to travel and often are able to go about in day trips. The photos in the living room have recorded
Beaufort House Version 1.10 Page 13 a variety of happy events in different locations. The home has two vehicles that ensure full access to the community. The residents were observed to receive a selection of food and drink for lunch. Meal times are designed around the residents needs. Their menus were varied and flexible. Residents attending cookery courses were encouraged to bring home and use their favourite recipes. Beaufort House Version 1.10 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. Resident’s needs were recorded in detail on every care plan inspected. They included specific details of personal support and how the resident preferred to receive it. The local health care professionals meet resident’s physical and mental health needs. Guidelines relating to the correct procedures for the storage, recording and distribution of medicines are followed by the home. EVIDENCE: Referrals were made to the local psychiatric team as required and the GP is also accessible. Residents appreciate the emotional support given by the staff who were observed to be laughing and joking with one resident and talking in a quiet and sensitive way with another. Specialised equipment is available at the home and is subject to assessment of need. Medications and creams are kept in separate metal cabinets to reduce the possibility of cross infection. The sample of care plans inspected included specific details of the residents medication .The correct prescribed doses had been given and recorded on the MARS sheet and signed by the administering staff member. A specimen of the staff members’ signatures and initials were also in evidence. Medication returned to the local pharmacy is recorded in a “returns book”.
Beaufort House Version 1.10 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 Complaints procedures require additional information. Residents were observed freely expressing themselves and communicating their needs to staff in a variety of ways that help alert staff to their needs. EVIDENCE: The inspector did not note any complaints at this inspection. The Home is required to provide more details on how to guide the service users through their complaints system and to include , the timescale of the complaint, the system in use and contact details for the CSCI. Training records confirmed staff training in The Protection of Vulnerable Adults had been received and is ongoing. Staff are sensitive to the residents needs. Beaufort House Version 1.10 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,26,27,28,29, and 30. The Home is situated on a busy road so parking can be difficult dependent on the time of day. The home provides consistent light and airy rooms. All the communal areas were clean tidy and decorated in a way that is complimentary to the home. Residents were relaxed and at ease within this homely environment. EVIDENCE: Specialist equipment was in evidence and being used by residents to enable maximum comfort and practical access to bedrooms and communal living areas. Resident’s bedrooms reflected their individuality and looked comfortable. Kitchen units were in a state of continual repair and have come to end of their natural and useful life. The units were mentioned in the last report are now a potential liability to the resident’s safety. It is therefore a requirement that the kitchen units are replaced. Beaufort House Version 1.10 Page 17 The laundry room was observed to be clean, tidy and airy, and in use. The wall to the right of the entrance requires minor work to the plaster. There is a sink for staff to wash their hands in, but , there was no sluice facility for laundering heavily soiled items safely and without risk of infection, this is a requirement. Beaufort House Version 1.10 Page 18 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, and 36. Staff receive the full benefits of a comprehensive induction program and a commitment and support from management to provide quality training. Staff Moral was observed to be high and showed an enthusiastic workforce that was supporting the residents to improve their quality of life. EVIDENCE: Staff training schedule inspected showing the necessary training required to include, POVA, Safe Manual Handling, First Aid and Care of Medicine. All staff had received their Enhanced Criminal Record Bureaux (CRB) Check and one was for a worker that had not yet commenced employment at the home. Staff receive supervision regularly every 6 weeks. Outcomes are recorded and their work is monitored and appraisals are received annually. Beaufort House Version 1.10 Page 19 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) 39 The home seeks to consult with residents, their representatives and professional on a regular basis to address the quality of the service provided. The health and safety requirement polices and procedures were all in order. EVIDENCE: A Sample of monitoring forms containing feedback from three of the resident’s representatives were inspected. All comments made where positive and reiterated when a residents representative was consulted during the inspection. The manager had not received any completed forms from the visiting practitioners. The Premises also receive regular visit from the area manger and details are sent to CSCI. Beaufort House Version 1.10 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. 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 3 3 3 3 Standard No 22 23
ENVIRONMENT Score 2 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 3 3 3 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 2 2 Standard No 11 12 13 14 15
Beaufort House 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 x 3 x x Version 1.10 Page 21 16 17 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x Beaufort House Version 1.10 Page 22 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 1 Regulation 5.(1)(b,e and f,) Requirement Timescale for action 21-07-05 2. 30 13.(3) 3. 24 16.(2) (g,h) The Registered Person must ensure the Service Users Guide containes ,terms and conditions of the accomodation, amount and method of payment , the address and telephone number of CSCI is available , and that the complaints procedures are fully explained. The Registered Person must 21-07-05 ensure that suitable arrangements are in place to prevent infection and the spread of infection at the care home by providing a suitable sluicing facility in the laundry area. The Registered Person must 19-10-05 provide suitable kitchen facilities and equipment for preparation and storage of food that is safe for residents to use. 4. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations
Version 1.10 Page 23 Beaufort House 1. 2. 3. 4. Standard 1 6 6 39 It is recommended that the Statement of Purpose includes more details of the complaints process . Care plan details relating to personal care to be kept in the residents bedroom. It is recommended that any resident that is without a care needs assessment should be re-assessed. An annual development plan based on a systematic cycle of planning-action-review reflecting the aims and objectives of the residents and their representatives to be put in place. Beaufort House Version 1.10 Page 24 Commission for Social Care Inspection The Wharf Abbey Mill Business Park Eashing Surrey. GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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