Inspection on 19/10/09 for Beaufort View

This inspection was carried out on 19th October 2009.

CQC found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beaufort View 13/10/08

Beaufort View 26/10/07

Similar services:

2 Perhaver Park

The Vicarage

7 Hyde Road

St George`s

5 Seafield Road

Credence House

Radfords

Trevaylor Manor

Extracts from inspection reports are licensed from CQC, this page was updated on 16/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Beaufort View 1 Beaufort Road Southbourne Bournemouth Dorset BH6 5AJ Lead Inspector Tracey Cockburn Key Unannounced Inspection 19th October 2009 12:15 Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 3 SERVICE INFORMATION Name of service Beaufort View Address 1 Beaufort Road Southbourne Bournemouth Dorset BH6 5AJ 01202 418877 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) beaufortview@tiscali.co.uk www.ventanahomes.co.uk Mr Henri Moocarme Mr Paul Anthony Greenwood Mr Andrew Michael Watson Care Home 8 Category(ies) of Learning disability (8), Physical disability (6) registration, with number of places Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home providing personal care only - Code PC to service users of either gender whose primary care needs on admission to the home are within the following categories: Learning disability (Code LD) - maximum of 8 places Physical disability (Code PD) - maximum of 6 places The maximum number of service users who can be accommodated is 8. 2. Date of last inspection 13th October 2008 Brief Description of the Service: Beaufort View was registered as a care home for up to eight people with learning and / or physical disabilities in June 2007. The home is owned by a partnership of four people who also own two other services for people with disabilities in the Bournemouth area. The home is an older-style detached property, in keeping with other properties in the neighbourhood, which provides accommodation on three floors. All bedrooms have en-suite facilities. There are three single bedrooms on the ground floor which are accessible to people who use wheelchairs. There are a further four single bedrooms on the first floor which can be accessed by a passenger lift or by stairs. The second floor, accessible only by stairs, has facilities for self-contained accommodation for one person including a bathroom and kitchen facility. A separate adapted bathroom facility is also available on the first floor which is equipped for people who have specific hoisting needs. Two separate toilets are also available for use. The home has a spacious lounge and conservatory which is also used as a dining room. The conservatory has patio doors which lead onto a paved garden area. There is a domestic-style kitchen and a laundry facility in a separate area outside the main house. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 5 Beaufort View is situated in a residential area of Southbourne, close to local shops and amenities. A bus route to Bournemouth and Christchurch town centres is located nearby. People who use the service have access to an adapted vehicle to promote community access. There is parking for this vehicle in the home’s driveway. Fees charged by the home are based on assessment of individuals’ needs. Further information on fair terms of contracts and care home fees can be found on the Office of Fair Trading website: www.oft.gov.uk. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This inspection was carried out by one inspector but throughout the report the term ‘we’ is used to show that the report is the view of the Care Quality Commission. This was a key inspection and was unannounced. At the time of the visit there were eight people living in the home. In preparation for the visit we sent out surveys to people who use the service, people who work in the service and health and social care professionals. We received three survey forms from people who use the service, three from health and social care professionals and three from people who work in the service. Their comments are used throughout the report. We looked at the information the home send to us in the annual quality assurance assessment; this provides us with information on how the home thinks it is doing in terms of providing good outcomes for people and how they plan to improve as well as giving us numerical data on different aspects of the service. During our visit we spoke to the acting manager as well as staff who work in the home and three people who live in the home. We observed daily life and toured the home. We looked at care records, staff files and training information as well as medication records and activities. What the service does well: People only move into the service once they have had a full assessment of their needs and the home has been clear that they are able to support them. Each person has an individual plan of their care which changes to meet their changes needs, wishes and aspirations. The home recognises the need to ensure that people participate in activities which are age, peer and culturally appropriate. People who use the service are supported to maintain contact with the people in their lives who are important to them. People have their rights respected in their daily lives. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 7 People are supported to maintain a healthy diet. People who use the service receive personal support in the way they prefer and need. People who use the service have their physical and emotional needs met. What has improved since the last inspection? At the end of the inspection in October 2008 there were seven requirements and twelve recommendations. A further two requirements and one recommendation were made at the pharmacy inspection in May 2009. Medication policy, practice and training in the home have improved and there are now audit systems in place to ensure medication is managed well from the moment it arrives in the home. Improvements to recruitment practice ensure that people who use the service are protected. Improvements to training mean that people who work in the home have more opportunities to develop their skills and knowledge. The registered provider visits the home each month and completes a report which is kept in the home. The home has a quality assurance system in place to listen to the views of the people who use the service. All incidents and accidents in the home are reported to the commission, this ensures we know how the service is handling situations and ensures that people are protected. A total communication approach has been developed with staff being supported to complete training and individual communication passports being developed. Risk assessments contain enough detail to ensure that risks are fully minimised. Staff levels are adjusted to meet changing needs of people. There is a medication audit trail in place to ensure that medication is being given as prescribed. The complaints procedure has a clear timescale for responding to concerns. The home is well maintained. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 8 Recruitment practice has improved. There is evidence that all staff training certificates are held in their personnel files. All staff have completed first aid training which means there is always someone on duty who can respond in an emergency. What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 9 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 View DS0000069692.V378163.R01.S.doc Version 5.3 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 2 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home ensures that they have sufficient information about people’s needs before they move in to promote a smooth transition. EVIDENCE: There have been no new admissions to the home since the last key inspection. The annual quality assurance assessment tells us: “Since the last inspection we have re written both the Moving In Assessment and the Statement of Purpose, Both of these are now available in an appropriate format. These documents are now relevant to the services provided by Beaufort View wheras previously they were documents we inhereted when we first opened. The Moving In Assessment has been re written within the last 4 months, in line with guidelines for such a document. It provides a tool for a comprehensive needs led assessment. It demonstrates the information needed to enable prospective residents to make choices about living at Beaufort View. The views of all those who know the prospective resident best are able to Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 11 record their views. The Moving In Assessment highlights any possible gaps in the services provided at Beaufort View.” Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 12 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care workers have good levels of information on which to base people’s care and meet their individual needs. EVIDENCE: The annual quality assurance assessment says: “* Staff have undertaken total communication training where they can * We have invested in purchasing packs of Signalong and Makaton signage for use in care plans, around the house and in other documentation. * We have invested in training for our Assistant Manager to enable them to deliver and certify total communication training. This was done partly due to the frustration in a lack of both training courses and availability of spaces on these courses.” Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 13 We looked at care plans for two people, one care plan had recently been reviewed and contained information on daily routines, communication and their daily support needs. We found there was a gap in reviews for one person between May and September. A health care professional who returned a survey forms said under the heading ‘what does the service do well’: “Their person centred approach and their skills to engage with service user” Another social care professional wrote that they do the following well: “Supporting high support needs clients” Work has begun on making care plans more person centred and written from their perspective. We observed during our visit that people are able to make choices about their daily lives, whether they help with meal preparation or decide to go out or stay in their room. Risk assessments are in place for people and cover a variety of topics both inside and outside the home. In the annual quality assurance assessment the manager stated they are working to enable people who use the service to make choices which involve risk in a more positive way. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 14 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): This is what people staying in this care home experience: 12,13,15,16,17 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home works with people and their representatives to develop activities which they are interested in and wish to do. People are supported to participate in activities in the local community and use local leisure facilities. People are supported to maintain a healthy diet. EVIDENCE: There are five people who live in the service who currently attend college, we spoke to one person who said they enjoy going. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 15 During our visit we observed that there are lots of DVD’s available for people to watch in the lounge, we did not notice any books or games in the lounge for people to make choices of what they want to do to relax. We were told that one person really enjoys being read to. We were told that staff are already planning activities in the Christmas break and people have expressed a wish to go to the pantomime. The annual quality assurance assessment says: “Further develop plans around food shopping. Increase internal and external activities for our residents, to give a wider choice of activities. Better resource activities to achieve more consistant attendance for residents.” They also told us about the variety of activities available to people who use the service: “We have photographic evidence of the residents lifestyle at Beaufort View. Where photographic evidence is used, permission is sought from the resident. This pictorial evidence is hugely improtant as an aid to communication for the residents with the staff group and with their families. It also enables future choice making over activities.” We were told that they are currently working on communication boards for each person in their room where they can display their activities on a daily basis. A social care professional thought they could to the following better: “It has been a conflict with the service widening daily activities, I have requested daily diary with photos but this has been an issue. The family would like more community participation” We spoke with this social care professional and found that since they had written in the survey form the situation was better and a daily diary was accessible with photographs. A member of staff wrote: “They need to have more staff working on shifts so that all residents are given time so that their individual needs are met” On person who uses the service told us: “They help me live an enjoyable life and they get me out doing activities, which I love, and help cheer me up when I may be sad” A person who works in the home said: “It has a great focus on community inclusion with activities like carriage driving and college courses being offered to clients” Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 16 During our visit, a member of staff went to the local shop for some fresh vegetables for the evening meal and someone who lives in the home also went with them. One person who uses the service told us they could do the following better: “ offer more choice when it comes to meals, and not have a set time for lunch and dinner as sometimes I may have a later breakfast and may not be hungry at lunch and may miss out” During our visit we observed people being able to come into the kitchen and choose snacks for themselves when they wanted to. The nutritional needs for one person who uses the service were very clearly recorded and the advice for staff was very structured including how small they needed to chop the food for each meal, this included photographs. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 17 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are supported with their care in the way they need and prefer. Health care professionals are fully involved in supporting people to meet their physical and emotional needs. Improvements to medication practice ensure people who use the service are protected. EVIDENCE: A health care professional told us: “They work in the best interests of their clients and act on advice, comply with treatment plans and enable service users to make choices, be individuals and achieve goals” Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 18 We looked at the care plans for two people, both contained detailed guidance on how they need to be supported to maintain their mobility and to keep them safe. In the two plans we looked at there was evidence of advice being sought and this actively being completed this related to positioning in bed for one person. People who use the service and have epilepsy have care plans which contain information on how staff need to support the person and the action they need to take, there was evidence that these plans had been completed with the support of a health care professional. We could also see in both plans detailed information of on health care appointments with opticians, dentist and speech and language therapist. One person had SALT guidance in place. Care plans focused on the person’s strengths and abilities. The annual quality assurance assessment tells us of the changes made over the past twelve months: “Since this time we have invested heavily in medication training. Staff have been internally trained in the ordering, receiving and auditing of medication. We have re written the medication policy and have also written a Controlled Drugs policy and installed a Controlled Drugs cabinet. A record of all the medication trained staffs signatures is held. Pictorial evidence of all 1st Aid trained staff is displayed in the house. MAR sheets show all residents allergies, or where none are known this is stated on the MAR sheets. Handwritten MAR sheets reflect the full description of the medicine prescribed, dosages etc. Handwritten MAR sheets are signed by two medication trained members of staff at the time they are written. The use of any homeopathic medication has been agreed by the residents GP in writing.” Requirements were made both at the key inspection in October 2008 and the random inspection in May 2009. We found that the service has addressed all the requirements regarding medication and has put in place audit systems to protect the people who use the service. Medication is stored in locked cupboards in people’s rooms. This allows people privacy when taking their medicines and more control over when they are taken. The printed medication administration records that we saw had all been completed appropriately with signatures or codes for each administration. People had photographs with their medication administration records. We were told that there is an audit every two weeks Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Systems are in place to ensure that if people are unhappy with the service they can be confident they will be listened to and their concerns acted upon. Induction training for staff covers safeguarding further training for staff will enhance their knowledge and understanding. EVIDENCE: All three people who returned survey forms to us said they knew who to complain to and who to speak to if they were unhappy. The annual quality assurance assessment told us that there are been three complaints received by the service in the last twelve months and that all three were resolved within twenty eight days. The annual quality assurance assessment also says: “Beaufort View has a clear complaints policy and proceedure. This has been written in an appropriate format and copies have been provided for all residents rooms. The complaints proceedure within the front door of the property has been ammended to reflect the correct telephone numbers (including the Compaints Officers Number at Bournemouth Borough Council) and timescales for responses. Since our last inspection, where the outcome was adequate in this area, we Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 20 have commenced a register of concerns and complaints. The home has new policies in place on Whistleblowing and Protection of Vulnerable Adults. The home also has a policy on Deprivation of Liberty Standards. All staff have had Protection of Vulnerable Adults training as a minimum requirement under the Social Care Induction. All staff have completed or are booked to complete the Bournemouth Social Services safeguarding course. Both the Registered Manager and Assistant Manager have completed the Safeguarding for Managers course.” There has been one safeguarding investigation since the last key inspection. We looked at the safeguarding policy the home has in place and whilst it is detailed and clear on how people should be supported and action to be taken if abuse is suspected or disclosed the policy makes no reference to the Pan Dorset safeguarding protocol which means that staff are missing vital information about the action they need to take. We looked at the training matrix and there are some gaps in training with seven staff yet to do the course. Three people were due to complete the training at the beginning of November. Two people had completed the training in September and four staff in July. However we note in the AQAA that all staff undertake safeguarding training as part of induction. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People live in a homely and comfortable environment. Good infection control practice is not always followed when using the laundry room. EVIDENCE: We looked round the home; it was clean, light and airy. People have personalised bedrooms, with appropriate moving and handling equipment to meet their identified needs. There is a variety of seating in the lounge and the conservatory is spacious to accommodate the use of wheelchairs. The communal rooms are accessible to everyone; the only area of the home which is not accessible to everyone is the laundry room which is outside. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 22 The home has laundry facilities in an outbuilding to the side of the property. These comprise a ‘professional’ washing machine and tumble dryer. At present the laundry is not accessible to everyone who uses the service. There is a hand basin in the laundry area but there was no liquid soap or paper towels for people to use. The home has a policy on infection control which we looked at as part of the inspection process. This includes information on hand hygiene, protective personal equipment and dealing with bodily fluids. The home’s Annual Quality Assurance assessment tells us that twenty care staff have completed specific training in infection control, this being confirmed by the home’s training matrix. The home presented as clean at the time of the inspection. All the care staff who work in the home are responsible for cleaning the home there is no separate domestic staff employed; we observed at times during our visit that care staff have to undertake cleaning tasks which takes them away from their time with the people who use the service. There is a garage next to the main property which contains refrigerator and freezer facilities. This was also being used as a storage area for furniture. We were told at the last key inspection that there were plans to convert the garage into an office space, new laundry and new food storage area. We found at this key inspection twelve months on that this work had not begun but is still planned to take place. There is a patio area to the side of the property. We found that access round the building could be difficult as the ground was uneven and cluttered in places, the fencing round parts of the property was rotten and broken. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Training improvements ensure that staff have the skills and knowledge they need to do a good job. To ensure that activities with individuals are uninterrupted consideration should be given to the number and skills mix of staff on duty. Recruitment practice has improved and people who live in the service are protected by these improvements. EVIDENCE: Two requirements were made in this outcome area at the last key inspection, relating to recruitment and training. Twenty two staff work in the home, ten have NVQ at level 2 or above, we spoke to one member of staff who told us they were about to start work on level three. We looked at the staff training matrix and could see that five staff were working towards or had gained different levels in the Learning Disability Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 24 Qualification. We did not see any evidence that other staff were working towards this qualification. Someone who works in the home wrote: “All staff are given full training and they develop staff well” Since the last inspection six staff have completed Total communication training enabling them to have skills in supporting people with their individual communication needs, we saw how this has been developed around the home with the use of pictures, photographs and symbols. The deputy manager has undertaken more in depth training in total communication and will be able to train staff. One person who works in the service wrote under the heading ‘what could the home do better’: “ for me I feel that perhaps to much is being asked of the staff in terms of chores not only are the staff expected to support clients they are expected to also do the cleaning and cooking and this could have a negative impact on the clients” During our inspection we observed staff taking on not just caring roles but also cooking, cleaning and laundry tasks. Staff were observed supporting people to assist with cooking the evening meal, we did not see anyone who lives in the home being supported to do their laundry or to assist in cleaning chores, the latter tasks seemed to be the care staffs responsibility. At times people were left on their own in the lounge without staff support as they were busy with these other tasks. The annual quality assurance assessment tells us that work has been done over the past year to support staff in learning sign language such as makaton. One person who uses the service wrote in the survey: “There could be more staff and more outings at the weekend” During the visit we observed that on a number of occasions staff had to stop activities they were doing with people to focus on other tasks such as cleaning. On a board in the hall are photographs of the staff on duty throughout the day and evening. On the day of our visit there were three staff on duty in the morning and three in the afternoon. We looked at the recruitment files for two people, two written references had been sought and gaps in employment had been explored and recorded at interview. Proof of identity, criminal records bureau checks and POVA1st checks had been completed before starting work in the home. Signed terms and conditions were on file. It was not clear from the recruitment files if people who use the service were involved in the recruitment process. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 25 There is a structured induction in place for new staff who complete several days before working in the home. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Improvements to systems in the home ensure that people have their health, welfare and safety promoted and protected. EVIDENCE: Four requirements were made in this outcome area at the last key inspection. At the last key inspection a requirement was made that Regulation 26 take place and a record is kept in the home for inspection. We found that this requirement has been met and all monthly visits are clearly recorded and stored in the home. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 27 A health care professional told us they are: “A responsive establishment keen to improve and develop in the care of their residents” One person who works in the home wrote under the heading ‘what could the home do better’: “Communicate. Carry out what they say they are going to do” The registered manager has recently left the service and at the time of this key inspection the deputy manager was acting manager. A new deputy manager had just started and we were told this will ensure that each shift is covered by a member of the management team. The current deputy has the Registered Managers Award. At the time of this inspection the registered providers were in the process of recruiting a new manager. There is a quality assurance process in place which has been significantly developed since the last key inspection. We looked at the information collated by the home and discussed there plans for development. Since the last key inspection the home has been informing us of any incidents in the home. All staff have up to date training in moving and handling which was a requirement at the last key inspection. All staff are up to date with infection control, food hygiene and first aid training. The home has a fire risk assessment in place which has been updated with new information about a nominated protected area in the home which is able to withstand fire for sixty minutes. All fire equipment was inspected and a quarterly inspection took place on 10/09/09. The gas safety certificate was issued on 30/09/09. Some of the paths at the rear of the home are raised and could potentially be a tripping hazard. Windows on the first floor are restricted. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 28 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 X 2 3 3 X 4 X 5 X 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 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Version 5.3 Page 29 Beaufort View DS0000069692.V378163.R01.S.doc 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 Refer to Standard YA23 YA30 YA32 YA33 Good Practice Recommendations The registered provider should ensure that the information in the safeguarding policy and procedure is accurate and reflects the local authority protocol. The registered provider should ensure there is liquid soap and paper towels for people to use in the laundry area to ensure good infection control practice is maintained. The registered provider should ensure that all care workers hold a National Vocational Qualification in Care or are working towards this. The registered provider should consider the number and skill mix of staff to ensure that activities with people who live in the home are not interrupted. Beaufort View DS0000069692.V378163.R01.S.doc Version 5.3 Page 30 Care Quality Commission Care Quality Commission South West Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. 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