Inspection on 12/07/07 for Beaumanor House

This inspection was carried out on 12th July 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beaumanor House 15/06/09

Beaumanor House 10/05/06

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 Linda Clarke Key Unannounced Inspection 12th July 2007 10:15 Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 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.V341005.R01.S.doc Version 5.2 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.V341005.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaumanor House Address 34 Robert Hall Street Leicester Leicestershire LE3 5RB 0116 2664833 0116 2664833 Beaumanor.House@leicester.gov.uk socis209@leicester.gov.uk Leicester City Council 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) Mrs Pauline Uliasz Care Home 21 Category(ies) of Learning disability (21), Physical disability (1) registration, with number of places Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No person falling within category PD may be admitted to Beaumanor House unless that person also falls within category LD - ie Dual Disability Service User Numbers LD/PD No one falling within categories LD/PD may be admitted into Beaumanor House when there is already 1 person of categories LD/PD already accommodated within the home. 10th May 2006 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 a learning disability. The home is owned and managed by the Department of Adults and Community Service of Leicester City Council. 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 it 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. 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.V341005.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection process consisted of pre-planning the inspection, which included viewing the previous Inspection Report, reviewing of the Annual Quality Assurance Assessment (AQAA), and Comment Cards sent to service users by the Commission for Social Care Inspection, six service user and seven relative Comment Cards were returned. The unannounced site visit commenced on the 12th July 2007 and lasted 1 day. The focus of the inspection is based upon the outcomes for the service users. The method of inspection was ‘case tracking’. This involved identifying service users with varying levels of care needs and looking at how these are being met by the staff at Beaumanor House. Four service users were selected and discussions were held with one of them, additionally three service users accessing respite services were spoken with. The method of case tracking included the review of service users’ individual care records, discussions with staff of various delegated responsibilities within the home and reviewing the records, training records and the minutes of service user and team meetings. Of the Comment Cards returned by service users comments received were generally complimentary about the care, a majority being completed by their relative. What the service does well: Service users have access to information about Beaumanor House when considering a placement at the home. Service users are confident that their needs are assessed prior to accessing Beaumanor House. Service users have a care plan prepared by both a Social Worker and the staff at Beaumanor House in consultation with themselves, these are supported by Person Centred Plans which provide staff with detailed information as to the needs of the individual service, which includes their views, goals and aspirations. Service users have the benefit of a range of activities within the Home, which includes board games, a Pool Table and Computer room. Service users are supported to maintain their health and have access to a variety of health care professionals. Service users have access to a Complaints Procedure, and can be confident that issues of concern they raise are dealt with efficiently and effectively. Service users can be confident that any issues reported which directly affect their welfare are pro-actively managed by the Registered Manager. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 6 Service users are supported by staff that has a National Vocational Qualification in Care. Service users are encouraged to share their views within service user meetings. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users relatives when asked what the home does well the following comments were made:• • • • I think they are okay at providing respite Staff are very very caring towards (service user name) and have always got in contact with changes to his health Their expectations are high and they will always help my brother to make his life as full as possible. Got very dedicated staff who always have time for parents and family What has improved since the last inspection? What they could do better: Service users whose first language is not English would benefit from having quicker access to the Homes Service User Guide, and could be improved by incorporating photographs of the Home environment. Service users need to be confident that they are protected from harm and abuse, this can in part be achieved by staff receiving the appropriate training, and by the assessment of current issues which currently affect the day to day running of the Home, and any appropriate measures introduced. The central courtyard needs to be maintained in order that service uses have the benefit of accessing an area for relaxation. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 7 The Local Authority to set up a system where by Regulation Inspectors employed by the Commission for Social Care Inspection can confirm by the viewing of records that staff have had a Criminal Record Bureau disclosure. Service users and their relatives/carers should be afforded a formal opportunity to take part in a Quality Assurance process, which seeks their views and comments as to the service they receive/experience. The results of the process to be communicated by way of a report, which includes information as to how the service intends to address any issues of raised and improve the service it offers. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users relatives when asked what the home could do to improve the following comments were made: • • • • • • I wish my relative did not have to move, but the home is changing to provide respite care only. Better communication with carers. Better monitoring of how clients savings are spent. A better understanding of clients privacy. It could be improved by better staffing levels. (service users name) has been a resident at Beaumanor House for 26 years, I used to feel that Angela was safe and caring environment and this would be her home forever. But since respite patients are attending more and more, I don’t feel (service users name) is in a safe environment. 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. The summary of this inspection report can be made available in other formats on request. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals considering accessing Beaumanor House benefit from documentation detailing the services offered. The admission process it well managed, giving prospective service users the opportunity to visit and ‘test drive’ the home to ensure that care needs can be met. EVIDENCE: Beaumanor House has a Statement of Purpose which details the range of services it offers which includes information as to whom the service is aimed at, its aims and objectives, the environment, activities and details as to how referrals are made to the Home and information on staffing including their numbers and training. Beaumanor House in addition to the Statement of Purpose produces a Service User Guide, which is in produced in large print and incorporates symbols to promote understanding. The Registered Manager said the document could be made available in alternate languages but are not kept on site and would have to be requested, given the diverse ethnic mix of service users accessing the Home; the document should be Home could improve the Service User Guide, Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 10 additionally the document should include the views of service users who access Beaumanor House. Service users are supported by staff that have a clear understanding of their needs, and have the appropriate skills and experience. Staff are able to communicate with service users effectively, as was observed on the day of the site visit. Service users who access Beaumanor House for respite (a short break) access the service either as a result of an emergency situation or a planned stay. Service users who regularly visit Beaumanor House for planned respite care, have had their needs assessed which in part identifies the frequency of the respite care they receive. Service users accessing respite following an emergency situation i.e. family emergency are assessed prior to their admission. Prospective service users and their relatives/carers are encouraged to visit the Home, spending time including overnight stays to ensure that the Home is suitable for their needs and meets their expectations, where practicable. On the day of the site visit the Registered Manager gave a guided tour of the Home and information to a prospective service user and their representative. As part of the site visit four service users were ‘case tracked’ which including viewing their initial assessment, two of the service users had both resided at the Home for many years, but had recently had their needs re-assessed with a view to moving out of Beaumanor House. The other two service users were accessing Beaumanor House for respite; both had a detailed assessment of their needs, which included plans for their future. Service users who were spoken with on the day of the site visit, confirmed that they had received information about the Home when they moved in, in addition the Service User Guide is laminated and is on the wall of the Dining Room. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users relatives a majority indicated that they receive sufficient information about Beaumanor House. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users independence is promoted and they 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: The care plans and records of four Service User were viewed, of which two were currently accessing a short break, and two lived at the Home. Care plans gave a detailed account of the support individual service users require, including personal and emotional support, lifestyle preferences including information on activities and day care. Service user care plans also provided guidelines on how to support service users with their emotional and health care needs and modes of communication. Care plans were signed by the service user or their representative, and are regularly reviewed, the involvement of service users in the review process is Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 12 dependent upon their individual needs, on the day of the site visit service users spoken with who were their for respite confirmed that a member of staff sat with them and drew up their care plan in consultation with them. Care plans are supported by Person Centred Plans, which place the service user as the central figure, and detail the support they require and include their goals and aspirations. Risk assessments are in place where an activity, event or the environment may present a risk to a service user, the assessment enables staff to support the individual to participate in daily living whilst not restricting their independence or choices. The daily records of the four service users were viewed, written information confirmed service users day to day decisions, for example what they wished to eat, when they wanted to go to bed and the choices of activity which they wished to participate in if any. Daily records also evidenced that the staff of Beaumanor House are pro-active in supporting service users to make decisions, and have positive communication with other agencies within the health and social care sector, enabling service users to make informed decisions and receive the support they require. Service users have the opportunity to take part in regular meetings, minutes of meetings are taken, which detail who took part and the issues discussed along with a record of any action, which needs to take place. Service users spoken with on the day of the site visit confirmed that they attend the meetings, and discuss various issues including their views on meals, day trips and holidays. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users relatives, a majority felt that the care needs of their friend/relative were met, and that they are given information about issues affecting their welfare and believe that the home supports their relative as they expect. Relatives made additional comments: • • • • • They don’t fully understand his needs I usually find things out from my son They are not very experienced in supporting an Autistic person I feel (service users name) could have more attention and support but I know this is hard due to staffing issues. I feel that the care home is more interested in respite patients. I know that (service users name) used to go out and about quite frequently – shopping etc. This is now not possible due to shortage of staff, which is a shame as I thought this was quality time for (service users name) Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 13 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): 12, 13, 14, 15, 16 and 17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users benefit from a range of activities, in some instances access to external activities is compromised. Service users do not benefit from a relaxed environment at mealtimes. EVIDENCE: Care plans and Person Centred Plans include information as to their daytime occupations, which vary for each service user and include attendance at various day centres and colleges and include transport arrangements. On arrival at Beaumanor House a majority of service users had gone out or were preparing to go out for the day, some service users remained at the Home during the day and were supported with their personal care and completing household chores. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 14 The Registered Manager in both conversation and information submitted to the Commission for Social Care Inspection (CSCI) confirmed that service users are not in all instances being supported to access community and recreational activities due to the home being short staffed, vacant posts are being advertised, which will hopefully improve the situation, this was supported by comment cards received from service users. Service users who were spoken with who were staying at Beaumanor House for a short planned break or as a result of an emergency situation said that they maintained contact with their family and friends. Daily records recorded relative and friend’s visits, and visits made by the service user. Service users who were accessing respite care spoke of the activities they were involved in, these included trips to the Cinema, going to Nottingham on the train, visiting Abbey Park, shopping and going to a Disco. The service users who had participated in these activities were able to do so with no or minimal staff support. Beaumanor House has a Computer Room, where service users are able to access the Internet. Service users spoken with all confirmed that they used the Computers; one service user showing me the news film footage covering a local charity event where he had undertaken voluntary work. A service user accessing respite gave me a tour of Beaumanor House, and discussed the activities she liked to join in, these included using the Computers and playing Pool, also that she enjoyed board games such as Monopoly. Beaumanor House is currently in the process of providing a ‘Snozelen’, which will provide an area for service users to relax, by incorporating coloured moving lights, and tactile surfaces. Service users do not benefit from a relaxed environment at mealtimes; the dining area was busy and noisy. Tables were set with a tablecloth, but not with flowers, cutlery or condiments. Service users queued at a serving hatch for their meals where they were able to choose from two options, earlier observations identified that additional choices are made available where service users make specific requests. Specialist dietary needs are catered for. One service user sat at the table eating soup whilst the remaining service users queued for there food, the environment was noisy this made it difficult for service users to sit quietly and enjoy their meal. Discussions were held with the Registered Manager about the mealtime environment, who acknowledged that mealtimes had been identified as a source of anxiety for service users. Recommendations for mealtimes were discussed with the Registered Manager, to promote a relaxed environment. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 15 Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user health care needs and independence is promoted by receiving timely care and support provided in the preferred way. EVIDENCE: Care plans highlight the way in which service users require support, and the use of equipment. Service user records detailed service users access to health care professionals, for some service users this was significant, the care plans were detailed and gave clear and concise information as to the support staff would need to provide in order to promote the health of the service user. Service users have a Health Action Plan on file, which identifies their specific health care requirements, one service user whose records were viewed had in their file information for nursing staff as to their specific needs so that their needs could be met whilst in hospital for an operation. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 17 The medication and records of four service users were viewed, all were found to be in good order, the care plan details the medication service users are prescribed, and issues such as the management of Diabetes are recorded in detail. A staff meeting had been held specifically to discuss the health care needs of one service user, and a Nurse specialising in Diabetes attended the meeting. Staff receive training with regards to the administration of medication, including medication which needs to be administered in an emergency situation, such as Diazepam when a service user is having an Epileptic Seizure. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are supported by a robust and accessible complaints procedure, whilst service users concerns are managed; service users are not always protected in the first instance. EVIDENCE: Documentation submitted by the Registered Manager prior to the site visit detailed that there have been eleven complaints with regards to the service, the concerns had been recorded and copies of the response to the complainant were kept on site. Information supplied confirmed that newly recruited staff receive training in how to look out for signs of abuse and how they are to respond if they have any suspicions or concerns. Beaumanor House currently has three ongoing investigations where issues of abuse have been alleged; this has resulted in two members of staff being suspended, and one being transferred to an alternative place of work. The removal of staff has had an impact on staffing levels, the shortfall being addressed in part by the use of Agency staff, and staff already employed working additional hours. Whilst these concerns are ongoing the Registered Manager has pro-actively managed these, and policies and procedures have been followed. irIt is also recognised that service users live, and staff work in an environment, which Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 19 encourages individuals to express concerns in the knowledge that their concerns will be acted upon. The Commission for Social Care Inspection were aware of these issues of alleged abuse, which were reported by the Registered Manager. Discussions were held with the Registered Manager who confirmed that the issues were ongoing, and continued to be dealt with by representatives of their department and other agencies such as the Police where appropriate. Following the site visit the Registered Manager’s, Line Manager contacted the Commission for Social Care Inspection to advise that a sum of money had gone missing from Beaumanor House’s safe, this was to be reported to the Police and to Leicester City Council Internal Audit Team. It was acknowledged that existing financial systems, which would have required checking the money on a daily basis, were not in this instance adopted. Service users were asked if they were aware of how to raise concerns, all confirmed that they had, discussions with one service user accessing respite care said that she had raised a concern and that the member of staff now worked somewhere else. Staff have received the first of a three day course in how to support service users by deflection or physical intervention who are challenging to both fellow service users and staff. It is considered a priority that all staff receive training in relation to their role and understanding in safeguarding service users from all forms of abuse, and that any interim measures are put into place to ensure the welfare of service users. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users relatives a majority confirmed that they were how to make a complaint, and that any concerns were responded to appropriately. One relative made an additional comment: • • Never had a major problem with the care home. If I had a complaint to make I would inform a member of staff, about any issues I have. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are provided with a warm, safe, clean, comfortable and wellmaintained environment suitable for their needs. EVIDENCE: Communal areas, bathing and bedroom facilities are located on the ground floor, all bedrooms are single and without en-suite facilities. Improvements have been made to Beaumanor House, which includes the introduction of the Computer Room, and a front door, which is accessible to individuals with a physical disability. Bathing areas in some instances have been refurbished, and service users have influenced the decoration of their bedrooms. Service users are able to access various communal areas; in addition to the lounges there is a recreational room that houses a Pool Table. There is a large garden to the rear of the property; the garden is mainly laid to lawn with mature trees and shrubs. Service users also have access to a central Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 21 courtyard, which consists of a patio with seating, plants and flowers. The grass however was overgrown and the beds unkempt. The area needs to be maintained for the benefit of service users. A laundry area is provided, with staff having the responsibility for the laundering of clothes. It was noted on the day of the site visit that when a visitor rings the front door bell this can be heard throughout the Home, a service user did comment very strongly that this annoyed them. The doorbell ringing potentially affects the ability of service users to relax, especially when a majority of the visitors are not visiting service users but are their to visit staff or maintain the building. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 and 36. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of trained staff meet the personal needs of service users, however in some instances the staffing levels are not sufficient to meet all their needs. EVIDENCE: Staff are encouraged to undertake a National Vocational Qualification in Care, currently 71 of the staff had attained the award. Staff receive training in a variety of topics which include issues relating to health, safety and welfare, and for newly recruited staff induction referred to as the Learning Disability Award Framework (LDAF), which covers topics that specifically relate to the care of adults with a Learning Disability. There is a staff development programme in place, the Registered Manager acknowledged that staff training has had to be prioritorised due to reduced staffing levels, as releasing staff for training impacts on service user care. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 23 Staff team meetings take place on a regular basis and are well attended by staff; the frequency of team meetings has reduced recently due to the reduced staffing levels. Staff receive regular supervisions, which are held with a member of the Management Team and provide an opportunity to discuss service user care, training, issues of concern and general practical issues regarding the day to day care of service users and management of the Home. Beaumanor has a low turnover of staff, however due to issues identified earlier in the Inspection Report, and staff sickness, day to day management of Home in relation to staffing has been problematic, the Registered Manager confirmed that a member of staff had recently been recruited and would hopefully start work in the very near future, and vacant positions would be re-advertised. The Registered Manager said that service users receive a high level of personal care, including meals however recognises that in some instances services users ability to access community events and leisure pursuits where staff support is required may be compromised. The Registered Manager spoke of the Local Authorities recruitment procedure, which is managed by a Human Resource Team. The Human Resource Team holds all records with regards to the recruitment of staff centrally; these records include the application form, references and a Criminal Record Bureau (CRB) disclosure. The Registered Manager that staff had renewed their CRB’s. Staff files do not contain any documentary evidence to confirm that a CRB disclosure has been undertaken, current policies and guidance issued by the Commission for Social Care Inspection, identify that when a large corporation employs the staff, a system needs to be in place whereby the Inspector can verify that staff have had a CRB, it is recommended that the Local Authority establishes such a system. The Commission for Social Care Inspection (CSCI) sent out surveys to a number of service users relatives a majority felt that the care staff have the right skills and experience to look after people properly. One relative made an additional comment: • They rely heavily on inexperienced bank staff Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is effective in dealing with issues reported to her. Service users are provided with opportunities to comment on and affect the service they receive, however this is not a formal process. EVIDENCE: The Registered Manager, Pauline Uliasz has worked within Learning Disability services for twenty-five years, and has been the Registered Manager of Beaumanor House since January 2006. Mrs Uliasz holds a Certificate in Social Service, but said she would like to undertake the Registered Managers Award. Service users spoke of their participation in service user meetings, which are held on a regular basis, those service users accessing respite join in with those Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 25 residing at the Home. Service users said they discuss the meals, activities and issues about Beaumanor House. Service users and their relatives/carers and others involved in the care of service users such as health care professionals could influence the service with greater effect if they were to take part in a formal quality review process, this could include questionnaires being sent to parents/carers and service users. An audit of responses could then be published and given to relatives/carers and service users including an action plan of any issues raised. Discussions were held with the Registered and Deputy Manager as to how information can be shared and gathered with regards to service users and their relatives/carers. Suggestions included the use of a newsletter for all, and systems to ensure that relatives/carers are given information following a service users respite stay were identified. Information submitted prior to the site visit detailed the regular maintenance of health and safety systems within the home, including fire systems and equipment, environmental health visits, central heating systems and emergency call systems. Records detailing fire drills and checks were viewed, and found tests to be carried out on a regular basis. Two service users spoken with confirmed that their had been a recent fire drill. Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 26 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 2 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 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 X 36 3 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 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 1 X X 3 X Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 27 Not applicable 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 YA23 Regulation 13 (6) Requirement Timescale for action 12/09/07 2 YA39 24 (1) The Registered Person to ensure that service users are protected from harm or abuse by the appropriate training of staff, and by assessing as to whether any other measures need to be introduced to ensure this. 12/10/07 A Quality Assurance process to be introduced, which provides service users, relatives/carers a formal opportunity to comment as to the service they receive. The Quality Assurance process should be open and transparent, with participants being given a report as to the outcome of the process, which details any actions the Home intends to introduce as a result of the audit. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000031587.V341005.R01.S.doc Version 5.2 Page 28 Beaumanor House 1 Standard YA1 It is recommended that information as to the services offered by Beaumanor House as detailed in the Service User Guide be improved through the inclusion of photographs of the home, and to be readily accessible in alternative languages reflective of the needs of service users to whom a service is offered. It is recommended that how mealtimes are currently conducted be reviewed, by encouraging service users to sit at tables, which are laid, and that meals are served to service users by staff from a trolley, which maintaining choice.. It is recommended that the courtyard garden area be maintained, providing service users with a relaxing but safe environment in which to relax. It is recommended as good practice, consistent with CSCI policies and procedures that the Local Authority devises a system whereby Inspectors can ascertain and confirm that staff have had a Criminal Record Bureau disclosure. 2 YA17 3 4 YA24 YA34 Beaumanor House DS0000031587.V341005.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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.V341005.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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