Inspection on 21/11/05 for Beaufort Street (112)

This inspection was carried out on 21st November 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beaufort Street (112) 18/04/07

Beaufort Street (112) 18/11/04

Beaufort Street (112) 14/05/04

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Beaufort Street (112) 112 Beaufort Street Nelson Lancashire BB9 0BT Lead Inspector Mrs Keren Nicholls Announced Inspection 21st November 2005 4:00 Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 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 Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 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. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beaufort Street (112) Address 112 Beaufort Street Nelson Lancashire BB9 0BT 01282 690703 01282 690703 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) Pendle Residential Care Limited Mrs Ann Suleman Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection The service may accommodate up to a maximum number of 2 service users in the category mental disorder, excluding learning disability or dementia (MD) 15th September 2005 Date of last inspection Brief Description of the Service: 112, Beaufort Street (accommodating 2 younger adults) is part of Pendle Residential Care Ltd. Dispersed Homes Scheme. This is a semi-independent living scheme for younger adults who have mental health problems. This dispersed house has staff support according to the assessed need of the residents. A designated house keyworker visits at least once a day and care support is available in the evening and at week-end as needed. Senior staff are on call at night and 24 hour emergency support is provided by the core house at Pendleview. Further support is provided by visits from the registered manager and provider. Beaufort Street is an end terraced house, located in a quiet residential area near to Nelson town centre shops and other amenities. The house has onstreet parking, a small front garden area and a private back yard. There is a large outside utility/store room. Transport in staff cars is provided for residents. Upstairs are 2 single bedrooms and a house bathroom. Downstairs are a kitchen, dining/living room and front lounge. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second visit carried out to Beaufort Street during the inspection year April 2005 to April 2006. The visit took place between 4:00pm and 5:20pm. Earlier in the afternoon, the inspector visited the core house (Pendleview) and spoke to the registered manager. During this visit the inspector spoke with both the residents and the house keyworker. She examined written information, including care and other records and looked at the house. The specialist pharmacy inspector visited Beaufort Street at the same time and looked at the medication. Her recommendations are made separately and will appear in the next inspection report. What the service does well: What has improved since the last inspection? What they could do better: One resident’s bedroom needed refurbishing. He was to have a choice of carpet and the drawers needed mending. To ensure the safety and protection of residents, the manager must keep all the records listed in the Care Home Regulations (such as an accident record) at the home, rather than at the core house. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 6 The manager should ensure that residents have all the information they need to make choices, such as what the home’s insurance covers, whether they need extra insurance for their belongings and the situation regarding a TV and TV licence. 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. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 7 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 Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 8 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 the following standard(s): 1, 2 and 5 Residents had up to date information about the home, which enabled them to make an informed decision about continuing residence. Contracts (terms and conditions of residence) were reviewed with each person, so everyone knew what their rights and responsibilities were, although insurance arrangements needed clarification. Needs had been properly assessed. EVIDENCE: The Statement of Purpose and the Service User’s Guide had been reviewed and updated. Both residents said that they had discussed their contracts with the house keyworker and were satisfied that they understood the content. Signed copies of all documents were kept in resident’s personal files at the home. The contract mentioned insurance for personal effects, but no one was sure what this covered, or the amount of cover. This should be clarified for each resident and recorded. If necessary, residents should be advised about personal insurance (see Standard 23.6). Trained people had assessed residents’ needs and plans described how changing needs were to be met. Everyone thought the staff and the home met their needs very well. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 6, 7 and 9 There were good arrangements to regularly review care plans with residents, based on the Care Programme Approach. Independence was encouraged and residents had continued support from designated care workers to take responsible risks and have choices in everyday life. EVIDENCE: Residents gave their permission for the inspection of their care plans. Plans were up to date and documented changes. Residents were involved in care plan reviews with the home’s staff and mental health professionals, which ensured their changing needs were known and met appropriately. Each person’s needs were considered in risk assessment and management. Both residents were well aware of their abilities, limitations and personal safety. They said they were very happy with the staff support and described how staff encouraged and enabled them to make decisions about their lives and about living independently. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 10 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 the following standard(s): 11, 14 and 17 Residents had flexible support to enable them to lead fulfilling lives, and participate in leisure and social activities of each person’s choosing. Staff helped residents with personal development and independent living skills. Healthy eating was promoted. EVIDENCE: Both residents were very complimentary about the keyworker’s support in helping them with personal goals, such as confidence building, living independently and improving their mental health. They thought that living at Beaufort Street was good for them. They enjoyed each other’s company and spent a lot of time together socially, but also had individual hobbies and interests inside and outside the home. The residents said they had recently reviewed the household tasks and had a new ‘rota’ for cleaning and tidying. Each person made individual choices about food shopping. One resident who enjoyed cooking made very appetising, varied and nutritious meals for them both. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 18, 19 and 20 Staff provided personal and healthcare support for individuals in a flexible manner that respected each person’s privacy, dignity and independence. Recommendations about medicines management will be made in a separate report. EVIDENCE: Residents said that they continued to make choices about daily living routines and the level of help they needed. Residents said staff were very supportive in mental health reviews and in ensuring that their best interests were known and represented. Records showed that appropriate personal and healthcare support was given in a timely fashion, to ensure resident’s health and wellbeing. The pharmacy inspector carried out an inspection of the medication and discussed this with the house keyworker. Recommendations and advice will be given in a separate report. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 12 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 the following standard(s): 23 Procedures were in place to respond to suspicion or evidence of abuse. Residents and staff had a good understanding of protection issues. EVIDENCE: Robust recruitment and selection procedures were followed, to ensure that staff were properly ‘vetted’ and suitable to work with vulnerable adults. The manager supervised staff to ensure their continuing suitability. Protection policies and procedures were available in the home for residents and staff to read. These included those to protect the financial interests of residents and ‘whistle blowing’ in the event of suspicion of abuse. The keyworker had received training in the prevention of and the action to be taken in the event of abuse. Policies and practices should advise on personal insurance. Residents said they felt safe at the home and had no concerns regarding any protection issues. They understood how to help themselves to be safe and had discussed such matters with their keyworker. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 24, 25, 26 and 27 The house was non-institutional and suitable for its stated purpose of supporting younger adults who have a mental health problem. The premises and outside areas were maintained in good order, providing a comfortable and ‘homely’ environment, suited to the needs of the current service users. EVIDENCE: Beaufort St is a good-sized two-bedroom terraced house, similar to other houses in the locality and near to shops and amenities. The residents said they liked their house and were comfortable and happy living there. The house was well maintained. It was warm, clean and had appropriate ventilation. Residents had personalised the property with their own belongings and made it ‘homely’. Residents gave permission to look at their bedrooms. Each person had a spacious single room with door lock. There was information about room sizes in the home’s statement of purpose. One resident said he was waiting for a new carpet to be fitted and was thinking about redecorating his room. The chest of drawers needed mending. The house bathroom had a bath (with shower over), was near to bedrooms and was appropriate for the current residents. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. However, it was noted there had been no changes since the last inspection when all the standards were met or exceeded. EVIDENCE: The residents wished to say that they were very happy with the staff, particularly their house keyworker. One person commented that the care worker was “champion” and he “wouldn’t change her for the world”. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 40, 41 and 43 Sound policies and procedures and business/financial plan, and properly kept records ensured the effectiveness of the home and the protection of residents. EVIDENCE: A full set of policies and procedures was available to residents and staff. Resident knew where policies were and had a good understanding of those that directly affected them (such as the fire, health and safety and security procedures). Resident’s personal records were well kept and up to date. One person needed a photograph. Residents said they could look at their files if they so wished. A record of occurrences should be kept in the fire log. Records of accidents and visitors must be kept at the home. Public liability insurance was up to date and a suitable business and financial plan had been submitted to the Commission. Residents said they discussed finances relating to the property with the registered provider. The manager needs to confirm personal insurance cover and the TV licence with residents. Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 16 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 3 3 X X 2 Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 4 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 X X X LIFESTYLES Standard No Score 11 4 12 X 13 X 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beaufort Street (112) Score 3 3 N/A X Standard No 37 38 39 40 41 42 43 Score X X X 3 2 X 2 DS0000009628.V267897.R01.S.doc Version 5.0 Page 17 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 YA41 Regulation 17(1)(2) Schs 3 & 4 Requirement The registered manager must ensure records include a photograph of each resident and keep records of accidents, occurrences when the fire equipment is operated and visitors to the home. Timescale for action 19/12/05 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 YA5 YA23 Good Practice Recommendations The registered manager should clarify insurance cover for resident’s personal belongings (5.2(v)) – see also Standard 43.3 and 43.5. Policies and practices should advise residents on personal insurance (23.6). Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB 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 Beaufort Street (112) DS0000009628.V267897.R01.S.doc Version 5.0 Page 19 - 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. 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