Inspection on 10/05/06 for Beaumanor House

This inspection was carried out on 10th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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

Beaumanor House 15/06/09

Beaumanor House 12/07/07

Beaumanor House 27/10/05

Beaumanor House 22/05/05

Beaumanor House 25/02/05

Beaumanor House 16/12/04

Similar services:

Hillside

Applegarth

122 Scorer Street

St Marys Nursing Home

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

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

CARE HOME ADULTS 18-65 Beaumanor House 34 Robert Hall Street Leicester Leicestershire LE3 5RB Lead Inspector Rajshree Mistry Unannounced Inspection 10th May 2006 9:30 Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 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 Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 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. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beaumanor House Address 34 Robert Hall Street Leicester Leicestershire LE3 5RB 0116 2664833 0116 2664833 holtjool@leicester.gov.uk 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) Leicester City Council Mrs Pauline Uliasz Care Home 21 Category(ies) of Learning disability (21), Physical disability (1) registration, with number of places Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling within category PD may be admitted to the home unless that person also falls within category LD – i.e. Dual Disability Service User Numbers LD/PD No one falling within categories LD/PD may be admitted into the home when there is already 1 person of categories LD/PD already accommodated within the home. 27th October 2005 Date of last inspection Brief Description of the Service: Beaumanor House is a registered care home providing accommodation for up to twenty-one adults with learning disability. The home is owned and managed by Department of Adults and Community Service. Beaumanor House is located in a quiet residential area, close to local shops, pub and other amenities. There is a car park to the front of the home. Public transport routes are nearby and is approximately ten minutes to the city centre by car. Bedrooms are close to the bathrooms and toilets. The accommodation is on the ground floor with level entry access. All areas of the home are accessible for people using walking aids. Information about the service is provided to prospective and current residents within the ‘service user guide’. The ‘service user guide’ is also available in other languages and formats such as Braille, on request. The resident’s fees are means tested determined through the assessment of needs carried out by the social worker and can rise to a maximum of £515 per week. There are additional charges for outings, transport, activities, chiropodist and toiletries. The CSCI published inspection report is available at the home and referred to in the ‘service user guide’. The residents are informed of the findings of the CSCI inspection through the ‘Residents Meetings’ and given information how they can view a copy of the CSCI published inspection report. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection of this service consisted of pre-planning work undertaken prior to the visit to the home. This consisted of reviewing the last two inspection reports, review of the events that have taken place with the service since the last inspection, the information received from the monthly visits carried out by the home by the Registered Provider. This was followed by the site visit on the 10th May 2006 that lasted 7½hours, using the main method of inspection known as ‘case tracking’. The primary method of inspecting was case tracking the care of four resident living in the home. Information was gathered through checking resident records, discussion with the residents tracked and other residents at the home, observation of care practices and interactions between the staff and the residents, discussion with the staff, key-workers for the residents, discussion with the cook, a visiting relative and the visiting Community Care Worker. Observations were made of the care practices in accordance with the procedures for the service and how residents with limited communication express their views. The findings from the inspection was shared with the Registered and the Deputy Managers at the end of the visit. The CSCI “Have your say about . . .” comment cards were given to the Registered Manager to encourage and support the residents to express their own views about the service provided at Beaumanor House. Seven comment cards completed by the residents with the support of the staff and their relatives were received following the inspection visit and comments have been incorporated into the inspection report. The Commission for Social Care Inspection is inspecting Beaumanor House against the Care Standards Act 2000. What the service does well: Beaumanor House has a relaxed and friendly atmosphere that reflects the interests and the residents’ choice of lifestyle. Residents’ individual rooms are personalised and comfortable, whilst the lounges and the dining room are inviting. Residents are encouraged to engage in individual tailored social and leisure activities of interests, both within the home and in the community, supported by the key-workers, friends and other important people in their lives. Residents are involved in the home life and supported to make decisions on a daily basis. Comments received from the residents through the “Have your say about . . . “ questionnaire indicated that the residents care needs are always met, residents were confident that staff were aware of their method of communication, likes and dislikes and how they expressed themselves to show they have a complaint, are in pain or are unhappy. Staff have a good understanding of the residents needs and continuously work with the resident to promote their independence, pursue their interests and goals including maintaining contact with family and observe religious and cultural practice. The choice and the variety of meals offered are nutritionally Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 6 balanced, choosing the menus and meals from different countires that are home made. 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. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 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 Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 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): 2, 4. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The admission process it well managed, giving prospective residents the opportunity to visit and ‘test drive’ the home to ensure that care needs can be met. EVIDENCE: The Inspector identified four residents to be case tracked and viewed their care records. All four residents care files contained a copy of the initial assessment of care needs carried out by the social worker, looking at the residents health needs, personal care, mobility and communication, cultural needs, diet, medication, the capacity to make decisions, involvement in educational programmes, social and leisure interests. Although copies of the initial assessments are in place, these are out of date as the residents have been at the home for number of years and their health, social care needs and interests have changed. One resident tracked remains in hospital and arrangements have been considered to ensure that the social worker carries out a new assessment, when the resident is ready to be discharged from the hospital. The Inspector viewed the new process introduced to review and confirm that the assessment and plan of care remains the same for the residents that use the respite service on a regular basis. Discussion with a support worker nominated to key-work residents on respite stays confirmed that the review process has been beneficial and support the resident to enjoy their stay. New Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 9 residents are welcomed and use the information received in the assessment to engage with the resident to develop skills and pursue activities of interests. Comments received in the residents through the residents’ questionnaire included ”I have lived here for over 20 years and have initial visits prior to moving in to see if Beaumanor House was suitable for me” The Inspector observed two prospective residents visiting with family and the Community Care Workers. The visitors were given information about the home and also had a look around the home and an opportunity to see the residents and staff. The prospective resident indicated that she liked what she had seen so far. The Community Care Worker informed the Inspector that the staff are very helpful and encourage people to visit before making a decision to stay at the home. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 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 the following standard(s): 6, 7, 9. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Residents’ independence is promoted and are supported to make individual decisions in all aspects of their life that have a direct impact on the quality of care and choice of daily lifestyle. EVIDENCE: Residents’ plans of care being developed into person centred plans using information that is already known and drawing on information about the residents’ lifestyle through the key-workers, family and observations. Three residents person centred plans were viewed which showed that they need updating. The plans of care did show that residents had made choices about who helps them with their personal care, attending the temple, preference to having a shower or bath and preferring vegetarian meals. Other information included communication, religious observance, visit to or from family and attending the clubs, day centres, college and going to the pub located at the end of the road. The plans showed the resident’s personal goals such as “more contact with family”, “use of signs” and “moving into my own flat”. The plans made reference to risk assessments although not all the risk identified were assessed. One resident who is looking to move into his own flat felt confident Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 11 that the support he has had is beneficial to him being able to live more independently and has made friends at the local pub who he goes to the pub with. Another resident who communicates with signs and gestures had an ‘activities programme’ sheet showing the days she attends the different centres and participates in activities that suit her interests. However, there was no reference to the resident’s special diet needs, medication and procedures to follow in case of seizures occurring. The care plans and risk assessments viewed by the Inspector were shared with the Registered Manager who acknowledged that some essential information was missing. The Registered Manager gave assurance to update the risk assessments and person centred plans to ensure residents holistic tailored care needs are met safely and action plans are in place to follow in the event of seizures. Comments received from the resident’s questionnaire completed included, “the staff are always available to help me with personal care when I need it”, “although unable to speak, the staff understand my gestures well”, The Inspector spoke to the support workers on duty regarding how residents care needs are met and demonstrated a good awareness of the residents and the increasing opportunity to do more one-to-one work with the residents. The support worker showed the Inspector the work currently being undertaken to develop detailed person centred plans identifying the things the individual residents like and dislike from going to Beaumont Leys shopping, the choice of meals and identifying people of significant importance such as parents and siblings. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 15, 16, 17. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Residents enjoy, experience and participate in different activities of interests and are supported to maintain their preferred individual daily routines and choice of lifestyle with the support of the staff, if required. EVIDENCE: The residents have key-workers that work with the individuals to provide support for personal care and promote opportunities to engage in activities of interest. Care plans and daily records viewed for the residents tracked indicated that residents are supported to access a range of educational, social and leisure activities. Records viewed showed residents often go to visit their family or are visited by family at the home. The notice board located outside the dining room had photographs of trips attended by the residents this year, which included the London Eye, Safari Park, Cadbury’s Chocolate Factory and the Solid Sixties Night. There were photographs of individual activities attended by residents such as attending ceremony and social events at the temple nearby to participating in the Gardening Club. A group of residents told the Inspector they were going to watch a show “CATS” on Thursday night. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 13 The residents spoken with and observed indicated they do make daily choices from the time they chose to get up to how they spend the day. Several residents were out at the day centres or swimming, another resident had returned from the pub with friends in the local area. One resident was planning to go catch a bus into town after she had finished eating her sandwiches. Throughout the inspection visit, the Inspector observed residents moving freely around the home, retiring in the lounge to watch television, having a drink in the dining room, talking with a support worker or relaxing in the shade in the garden. The Inspector heard Asian music being played for a resident who enjoyed listening to Asian music and being spoken with in the residents’ family language by the support worker. Following the recent findings from the Quality Assurance survey carried out the Registered Manager is currently looking to identify work opportunities within the home such as clerical tasks. Since the last inspection a computer suite has been created for the residents. Two computers and other equipment are in place and training is planned for the residents ensure the programmes match their interests. Staff spoken with indicated that some residents enjoy using the computers to do jigsaws and artwork. The visiting relative spoken with indicated that residents are being supported to access a range of activities and social events. The relative was not happy with the range of food provided, as the resident does not eat vegetables, although the resident was offered an alternative meal. The Inspector spoke with the agency cook who was preparing the evening meal, which was paprika beef or paprika vegetables for the vegetarian residents. Meals are decided by the residents at the ‘Residents’ Meetings’, using pictures. The menu plans displayed in the dining room ranged from mousaka, curries, fish pie, sweet and soar pork with egg fried rice and vegetables, salads, homemade soups, sandwiches to deserts and home made biscuits. Most of the residents indicated they enjoyed the variety of the meals, whilst the Inspector was directed to the pictorial menu boards in the dining room. Staff spoken with stated that the residents’ have been involved in preparing the pictorial menus and trying different meals such as curries and mousaka, in addition to pizza, pies and chips. Comments received through the residents questionnaire included “The staff always take me to interesting places, I love Liverpool and Cadburys World”, “I would like more in house activities which will hopefully be happening soon”, “I have difficulty chewing, so meat is a problem, even when cut up”, “I am unable to eat but drink Fortisips drinks to sustain me”, “Staff are aware of my preference and cater for my diabetes”, and “ I like to phone my family regularly, they also visit me a lot”. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 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 the following standard(s): 18, 19, 20. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The residents’ health care needs and independence is promoted by receiving timely care and support provided in the preferred way. EVIDENCE: The current residents living at the home have varying levels of independence although are supported to maintain their own abilities as far as practicable with regards to personal care. Three residents spoken with indicated that the staff would help when required from their key worker. All residents including residents on short respite stays have nominated key-workers. Staff spoken with indicated that where possible the residents cultural needs are made known to ensure that any specific cultural needs are accommodated such as going to church or the temple or any specific dietary needs. One resident pointed out that the home has had a new shower and bath fitted and he prefers to use the shower room. The residents spoken with indicated they feel they are treated with respect and are given support to continue their preferred daily routines. Comments received from the residents through the questionnaire included “Any problems I have such as epilepsy are dealt with by trained staff. They also take me to the GP’s when necessary” and “staff and nurses help me to control my diabetes and I am looked after well if any medical concerns arise”. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 15 The care plans and daily records viewed for residents tracked showed named support worker assisting the resident to bathe and wash. Records also showed the monitoring that takes place with regards to sore areas on a resident tracked is recorded as he does not like going to the GP surgery although is happy for the GP to visit him at the home. The District Nurse was observed visiting a resident to administer an insulin injection, which occurs daily. The medication is stored in a locked room and administered by nominated trained staff. Medication for residents tracked were examined against the medication records and found to be correct and up to date. Emergency procedures for individual residents is now with the medication for easy access and clearly guides the staff to the treatment to be administered. Management, storage and recording of medication is good and showed medication is double signed at handover meetings with the staff. Residents were seen to receive their medication at the times specified by the GP. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 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 the following standard(s): 22, 23. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Residents are protected by robust and accessible complaints and by staff in the adult protection procedures. EVIDENCE: Beaumanor House has received cards and letters of thanks from relatives of residents that have used the service. No complaints have been received by the CSCI. One complaint was received by the home since the last inspection. Although the complaint record could not be found in the complaints log, the Inspector viewed the complaint and the findings of the investigation held in the residents file. The complaint was concluded to the satisfaction of the complainant, within the set timescale and improvements have been made as a result of the findings. The Inspector spoke to individual residents who were able to communicate who felt confident to tell the staff if they were not happy about something. The staff told the Inspector that residents would tell them if there were any concerns or use gestures or noticeable changes in behaviours to show there is a concern. Comments received through the comment cards in response to ‘how to make a complaint’ the responses received included “I am not able to verbally or in writing make a complaint but I have good family relationships and staff to call upon if required” and “by means of advocates/social workers/family and staff”. The Inspector spoke to a visiting relative who confirmed that a complaint had been made about the resident’s money going missing. The relative confirmed that the resident has a safe in the room and the room is lockable. On discussion with the Registered Manager it was noted that the complaint was not logged in the complaints log. However, the Registered Manager did have Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 17 the evidence to show the investigation that took place and the involvement of the relative. The Registered Manager confirmed that the residents risk assessment and plan of care has recently been reviewed with the relative to be implemented. The Registered Manager gave assurance that she would check with the relative that the complaint was concluded satisfactorily. Staff spoken with confirmed that safe guarding adults training had been covered in the Induction training. The staff demonstrated a good understanding of the types of abuse that can occur, their responsibility and procedures to follow in relation to safeguarding adults and whistle-blowing. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 18 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, 30. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. The residents’ benefit from having a newly redecorated environment that is well maintained and residents can personalise their living area in a way that promotes their lifestyle. EVIDENCE: Since the last inspection the home has undergone major programme of redecoration and refurbishment, which has made the home bright and created a welcoming atmosphere. Corridors are colour coded: green, pink and blue and involved the residents in choosing the colours. One resident showed the Inspector his bedroom, which was located in the ‘green’ corridor. A bedroom was personalised to show the resident’s interest in music, football and had new bedroom furniture. Residents have a choice of lounges, including a games room with a pool table in it. Residents spoken with were familiar to the provisions in the local area and where to find the bus stops and the pub. Comments received from residents through the comment cards included “I am looking forward to moving into my own flat in a few weeks” and “I have just moved bedrooms, I like my new room”. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 19 The visiting Community Care Worker and the prospective resident viewing the home indicated that they like the improvements made in the home, “it looks more homely, bright and the staff make it very welcoming”. The home has appointed a Premises Officer who is responsible for repairing minor faults and the maintenance in the home. The bathroom and shower room have been re-furbished, new tiling and flooring. A new bath with a hoist and a purpose built shower room with a shower chair have been installed and residents spoken with said they do like the new look. The home is on one level and is fully accessible to people using walking aids or wheelchairs. There is a disabled toilet for the residents and visitors to use. The laundry room is locked and located away from the kitchen and dining room. The Deputy Manager stated that one of the washing machines with the sluicing facility was broken and arrangements have been made to have a replacement machine. Staff spoken with confirmed they have received training in control of infection and have access to protective clothing and hand washing facilities in the home. Staff were observed assisting residents and wearing protective clothing when serving food and collecting the laundry, demonstrating that procedures are being followed. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 20 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): 32, 34, 35. Quality in this outcome is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of trained staff are recruited through a robust recruitment process ensuring that resident’s care and social needs are individually, collectively and safely met. EVIDENCE: The local authority’s recruitment procedure is robust, which is managed by the Human Resource Team. The Inspector examined five staff personnel and training files. The staff application forms and confirmation of the criminal records bureau (CRB) clearance and protection of vulnerable adults list (POVA) checks are held in the Human Resource team, although copies of references were on the file along with confirmation of the induction training, job description and certificates of training attended. At present the home has 45 of staff with NVQ level II and above qualifications. Staff spoken with confirmed additional training was provided in moving and handling, “reflecting on the work we do”, specifically with a focus on working in residential care. Training planned for the staff are: safe handling of medicines, and Person Centred Plan training. All staff have a personnel training and development portfolio and access training made available by the local authority’s training team. The new member of staff spoken with confirmed that she had completed the local authority induction training, consisting of health and safety, procedures, Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 21 safe guarding adults and the LDAF training specific to staff working with people with learning disability. Residents that spoke with Inspector felt that they were understood. The Inspector observed residents using gestures and signs to communicate with the staff to ask questions, have conversation and to express themselves. Residents were able to tell the Inspector the staff on duty, which was consistent with the staff rota. At present the home is using two carers and a cook from a team of regular agency staff. The resident indicated that there is always a member of staff on duty, all who are aware of any particular support they may require. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 22 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): 37, 39, 42. Quality in this outcome is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ health, safety and welfare are being promoted through consultation and could be protected more by using the set procedures. EVIDENCE: Beaumanor House now has a Registered Manager who underwent the CSCI process to demonstrate her fitness to manage the home. The Registered Manager has considerable qualifications, experience in care, working with people with a learning disability and management experience. There are clear lines of management responsibilities of the staffing and training, the premises and budgets. The local authority has a training department and training is available to staff through a process of nomination. The Registered Manager confirmed that the local authority carried out a quality assurance survey of the learning disability services. The process commenced last year will be concluded this summer. The process considered the views of the residents and carers in the home and using other services for people with Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 23 learning disabilities. The interim findings indicated residents focused on their interests and desire to gain employment. The home is run in the best interest of the residents. Residents are consulted on a daily basis regarding their plans for the day, with key workers, at the formal review meetings and the monthly ‘Residents Meetings’, usually on a Sunday when all the residents are at home. The last minutes of the meeting viewed showed the discussion topics regarding the refurbishment in the home, planning of meals planning of trips, outings and shows. Residents spoken with felt they were listened too and their views respected. One resident who is planning to move into his own flat said the staff have been very good and helpful to him. The residents’, staff and health and safety records kept in the office. The records for the three residents were viewed, showed risk assessments in place for using the kitchen, sitting down in the middle of the road and mobility. These were discussed with the Registered Manager and assurance was given to update the risk assessments as part of the development of the plans of care. Beaumanor House now has a Premises Officer responsible for minor repairs and supported by the Maintenance Team, when required. Records relating to health and safety procedures such as regular fire drills and fire alarm tests are completed and were up to date. The storage of hazardous and COSHH (Care of Substances Hazardous to Health) materials is secure. Residents spoken with indicated that they felt safe both in the home and with the carers. The Accident book viewed detailing the events affecting the wellbeing of the residents and the actions taken. However, the same notifications were not sent the CSCI as required under the Care Standards Act 2000. The Registered Manager confirmed the omissions were in error and assurance given to submit the notifications on time with immediate effect. Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 24 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 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 25 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. Refer to Standard YA6 Good Practice Recommendations The Registered should ensure that the residents person centred plans are: • Holistic and continuously developed • Incorporate the control measures identified from the risk assessments, and; • Give clear guidance to staff on how to support and meet the care and social needs of the residents. The Registered Manager should ensure that the risk assessments carried out are current, up to date and incorporating any special requirements, choices and preferences to continue living a choice of lifestyle preferred. 2. YA9 Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX 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 Beaumanor House DS0000031587.V288672.R01.S.doc Version 5.1 Page 27 - 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. 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