Inspection on 15/02/06 for Beech Hill, 230 Spotland Road

This inspection was carried out on 15th February 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beech Hill, 230 Spotland Road 22/01/08

Beech Hill, 230 Spotland Road 30/10/06

Beech Hill, 230 Spotland Road 15/08/05

Beech Hill, 230 Spotland Road 24/01/05

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Beech Hill, 230 Spotland Road Beech Hill 230 Spotland Road Rochdale Lancashire OL12 6QD Lead Inspector Diane Gaunt Unannounced Inspection 15th February 2006 10.15a Beech Hill, 230 Spotland Road DS0000062677.V269802.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 Beech Hill, 230 Spotland Road DS0000062677.V269802.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. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech Hill, 230 Spotland Road Address Beech Hill 230 Spotland Road Rochdale Lancashire OL12 6QD 01706 651702 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) poppy.aj@virgin.net Pendleton Care Ltd Zoe Anne McCall Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 3 service users to include: up to 3 service users in the category of LD (Adults with learning disabilities) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 24th January 2005 Date of last inspection Brief Description of the Service: Beech Hill is a large stone semi-detached property, which provides twenty-four hour care for 3 young adults with learning disabilities on a long term basis. Care is provided by Pendleton Care Ltd - a company that specialises in the care of young adults with autism. The property is owned by a private landlord and comprises of 3 large bedrooms, lounge, dining room and dining kitchen. The house is indistinguishable from other properties in the surrounding area. It is situated in a residential area and is in close proximity to local shops, services etc and within easy reach of Rochdale town centre. A bus service passes the house. There is a lawned garden area to the rear of the house. A car park is not provided although on-street parking is available. Access to the main door is via one step. A lift is not provided in the house as none of the service users require such facility. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours on one day and 1¼ hours the next, when the pharmacist inspector visited. The home had not been told beforehand that the inspector would visit. The inspector looked around the building and looked at paperwork about the running of the home and the care given. In order to find out more about the home the inspector spoke with the manager, 3 support workers, the team co-ordinator, a relative and 3 service users, although discussion with 2 of the service users was very brief. What the service does well: What has improved since the last inspection? A full staff team was employed which meant that agency staff didn’t have to be used often and service users could get used to the small team of people caring for them. This had helped service users to settle into the house. Records of the support service users wanted and needed were kept up to date and regularly reviewed. All the paperwork needed to help staff work with service users to review their care was readily available and staff were reminded when it needed to be completed. This helped to make sure everything was kept up to date and any changes noted. Communication between staff was better and they worked well as a team, sharing information both in writing and verbally. This had created a better atmosphere at the house for service users and staff. The house was calmer. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 6 Training for staff had improved, all staff had had fire training and all but a newly recruited staff member had attended health and safety and autism spectrum training. Information about the house had been updated and copies given to service users, relatives and CSCI. A new lock had been fitted to the bathroom door and action taken to make the basement less damp. 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. Beech Hill, 230 Spotland Road DS0000062677.V269802.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 Beech Hill, 230 Spotland Road DS0000062677.V269802.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): EVIDENCE: None of these standards were inspected although feedback was given on the amended Statement of Purpose and Service User Guide and minor adjustments agreed. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 Detailed care plans which encompassed service users’ aspirations and needs were written, regularly reviewed with all concerned, and known and understood by staff to enable them to meet service users needs. EVIDENCE: Care plans were in place for each service user and were seen to be detailed and up to date. Staff interviewed showed knowledge of their content and indicated they were working consistently towards service users goals. One service user spoken with had knowledge and clear understanding of interventions in place, including expectations of her. She said she could look at her care plan with staff whenever she wished and all she had to do was ask. The plans covered a wide area including: personal profile, daily living skills, communication, and behavioural profile. The plans also identified potential adult protection safeguards. Detailed risk assessments and behavioural management strategies for challenging behaviour were in place and included input from the organisation’s behavioural psychologist. In addition to the care plan, service users had each begun work on their own person centred plans with the support of staff. Inspection of these plans provided evidence that service users were encouraged to express themselves and their views on the plans, which would be considered when next reviewing other care planning Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 10 documentation. Photographs were to be added, further personalising the document. Strategies, interventions and goals were reviewed after 3 months, and service users, relatives and care managers were involved in the process as part of the home’s quality assurance strategy. Symbols and pictures were used to ensure maximum service user involvement. In addition keyworkers reviewed service users’ aspirations and individual goals with them on a monthly basis. Observation and discussion with one service user provided evidence that staff were acting upon these aspirations. Service users and a relative spoken with said they were satisfied their needs were being met at Beech Hill. Since the last inspection staff had worked hard to motivate service users and to introduce new experiences to them. They met at the beginning of each week so service users could adjust their activities and introduce new ones if they wished. Activities were linked to planned goals and progress towards them monitored with service users. Each service user had a series of daily monitoring charts so progress could be logged and, where necessary, health/personal care needs monitored. This further ensured that staff were clear as to the needs and goals of service users. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 11 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): 16 and 17 The individual service users preferred daily routines were respected and service users independence and choices promoted. Dietary needs were well catered for with a balanced and varied selection of food, which met individual tastes and choices. EVIDENCE: Individual daily routines were in place for each service user and staff spoken with knew and respected them. Weekly activity planners were negotiated and agreed with each service user and reviewed at the beginning of each week. There was documented evidence that these planners were changed if service users changed their minds about an activity. Discussion with one service user and inspection of the planners provided evidence of staff’s flexibility and respect for service users’ rights and choices. Whilst choice and independence were upheld, in one instance where this had begun to adversely affect a service user’s health, staff had sought medical intervention and worked hard to motivate the service user. This was seen to have been effective. Observations made during the inspection, confirmed that staff communicated appropriately with the service users and used tried and tested techniques in order to motivate and encourage them in personal care and daily living tasks. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 12 Discussion with staff confirmed their consistent approach. Inspection of rotas showed that sufficient staff were provided to enable service users to pursue chosen activities. When planning the rotas staff said the manager took account of the need to have people on duty who could drive if a chosen activity needed to be accessed by car. Service users had freedom of movement throughout the house and grounds, although they did not access the garden during the winter months. One service user chose to show the inspector around the house and understood not to access other service users’ bedrooms without permission. Safety locks were fitted to bedroom doors and service users held keys. Service users did not go out unaccompanied, staff rather than service users held the keys to the front door. Risk assessments were not in place with regard to this arrangement. Service user were each involved in household tasks which were shared. Staff supported them in some of these activities. Each service user was supported to be independent in daily living activities and this was evidenced during the visit. Staff were observed communicating with service users and did so in a respectful way. Those interviewed were clear that the house was the service users’ home and respected it as such. Standard four weekly menus which were varied and nutritiously balanced were available and used as a basis for individual meal planning. Two choices were planned for each mealtime. Service users had different needs, likes and dislikes, and menus were seen to cater to these. A record was kept of the food each resident ate each day and was seen to reflect their individual needs and choices. Dietary advice had been taken in respect of two service users and was followed. Staff had negotiated healthy eating options with service users and built in treats to diets where this was appropriate. Service users were involved in menu planning and shopping. One service user was actively involved in preparing the main daily meal and washing up, and another was assisted to prepare some meals. Each was encouraged to lay and clear away tables. Mealtimes were arranged to fit around individual activities, the evening meal was generally eaten together. Meals out were enjoyed and on the day of the inspection one service user chose to have a pub lunch after going for a walk. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Personal support was provided in the way service users preferred whilst encouraging maintenance of physical and mental wellbeing. Physical and emotional health care needs were being met. Systems were in place to facilitate the safe handling of medication but the written medication policy needed to be reviewed to ensure safe administration at all times. EVIDENCE: Care plans stated what help service users needed along with their preferred routines. Staff said they followed these, ensuring consistency in approach. It was clear from interviewing staff that they knew each individual’s chosen routine and effective ways of working with them. They were able to give examples of how they ensured each person’s privacy and dignity needs were met in keeping with their choices. All the service users living at the house are female and an all female staff team had been appointed to provide their support. Service users were encouraged to do as much for themselves as possible and staff provided appropriate levels of guidance and support with regard to personal hygiene whilst respecting individual wishes. Progress in this area was monitored with service users when goals and essential skills were reviewed. In some instances daily monitoring was in place. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 14 On the day of the inspection staff were seen to encourage a service user to get out of bed and to have a bath. Another service user said staff always watched to make sure her teeth were cleaned properly. This had been agreed and was recorded on the care plan. Staffing levels allowed service users to go out in the evening if they wished and the provision of two night staff, one who slept and one on waking duty meant that there could be flexible bedtimes also. Service users received additional specialist support and advice as needed from diabetic nurse, dietician, podiatrist, optician, dentist, psychiatrists, and the organisation’s own behavioural psychotherapist. Staff supported service users to be as independent as possible in managing their healthcare. One service user who was diabetic was responsible for checking her own blood sugars, although staff administered medication. Each service user chose to be supported when attending medical appointments, staff interviewed said they would make sure the service user wished them to be there throughout the consultation before going in with them. They also said they would encourage the service user to answer questions put to them by health professionals rather than answering for them. All visits and involvement with health care professionals were recorded and information shared at handover. Health care needs were reviewed on a 3 monthly basis and changes recorded as they occurred. Food/fluid charts were in use when necessary and weight was regularly monitored. A record of self harm was also kept as appropriate. Where staff had needed to use physical intervention with a service user this was detailed on file. Only those staff who had successfully completed physical intervention training were permitted to use this method. Medication policies and procedures were available within the home but they need reviewing to ensure they reflect practice within Beech Hill. Homely remedies were used, but the written procedure had not been implemented. One client was supported to self-administer insulin; all other medication was administered by trained care staff; consent to staff administration was recorded within clients files. Records of medication received into and leaving the home were maintained. The medication administration records (MARs) were generally clear and up-to-date, but details of how medication was supplied to clients for administration away from the home were not recorded. Medication was securely stored. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Satisfactory policies, procedures and practices were in place in relation to complaints and protection, but service users were not fully informed on paper of the process to follow if they wished to make a complaint. EVIDENCE: The complaints procedure was included in the Statement of Purpose, with brief reference to it in the Service User Guides. There were two Service User Guides, one written for service users and the other for relatives and other stakeholders. The one written for service users was illustrated to aid understanding and, the inspector was informed, was explained with the use of symbols for one service user who was unable to read. Information contained in the section on complaints did not provide names or contact numbers for service users. It was not clear in the Service User Guide that CSCI could be contacted if necessary, and CSCI’s contact details were not included. However, one service user spoken with was clear that if she was not satisfied with the response to a complaint made to the manager she could speak to the divisional manager who visited the home. A complaints book was in place but no complaints were recorded. The manager and staff said that if issues were raised with them they were immediately addressed and therefore did not develop into formal complaints. Discussion with a relative confirmed that staff acted upon suggestions for improvement, negating the need for complaint. Interviews and inspection of quality assurance records further showed that service users, relatives and care managers were given regular opportunities to voice views and concerns. Appropriate policies and procedures in relation to the protection of vulnerable adults were in place and staff were not employed to work at the home before appropriate checks had been undertaken. Inspection of service users files Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 16 showed individual risk assessments were in place for the protection of service users and these were regularly reviewed. Physical intervention was used at the home only when necessary. Staff would first try to de-escalate a situation before using physical intervention as a last resort. Evidence of this approach had been seen on a previous inspection. All staff were required to undertake training in physical intervention. Records showed that all staff had completed the training although two were awaiting a refresher course and another was awaiting a second course in order to achieve competence. Staff were not allowed to use physical intervention until they were deemed competent by the trainer. Records were kept whenever physical intervention was used. Three staff, including the manager, had attended protection of vulnerable adult training. All but one recently recruited team member had undertaken NVQ training which included protection of vulnerable adults. The manager planned to cascade her recent training to all team members to ensure they had up to date knowledge. Staff interviewed were conversant with both the complaints and protection procedures and fully understood the concept of whistle-blowing. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 17 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 Whilst a homely, comfortable and safe environment was provided in the main, improvements were needed in one area. EVIDENCE: Standard 24 was fully assessed at the last inspection, follow up was undertaken at this inspection. The bathroom door lock had been refitted and action taken to eradicate the dampness in the basement. Arrangements were in place to replace windows, a number of which were leaking. During the inspection it was noted that the landing was in need of decoration and the carpet had not been replaced despite recommendation having been made at the last inspection. An environmental health inspection had taken place on 03 October 2005 and requirement made to reseal the area between the kitchen wall and worktop. This work had been completed. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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, 33, 34, 35 and 36. Service users were supported by a full complement of permanently employed and trained staff, ensuring consistency and stability. Recruitment practices protected service users. EVIDENCE: Improvement was seen in staffing provision in that agency staff and workers from other Pendleton Care houses were no longer relied upon to ensure minimum hours were provided at the house. Following recruitment in December 2005 a full staff team was in place. Staff morale was high and it was apparent from observation and interviews with staff that they worked well together as a team to provide consistent care to service users. Although staff meetings had not been held regularly, those interviewed felt well supported by the manager and received regular 1 : 1 supervision. Communication systems had been improved and were said to be working well. It was apparent from interviewing staff that they had up to date information as to service users needs and how they wished them to be met. Staffing levels were meeting these needs; this was evidenced from checking rotas, activity planners, care plans, reviews and feedback from care managers and relatives, as well as talking to staff and service users. An all female team had been recruited to ensure an appropriate gender match for the all female household. The inspector was informed there was a rigorous recruitment and selection system in place and that staff did not work at the house until a satisfactory Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 19 Protection of Vulnerable Adults (POVA) 1st check or Criminal Records Bureau (CRB) check had been obtained together with 2 written references. This information could not be fully verified as company policy is to store recruitment and selection records at headquarters. The manager did have records of CRB check dates and numbers along with names and addresses of referees but application forms, health declarations, references and copies of contracts were not held at the house. Of three staff files checked it was noted that the CRB of one recent employee was dated 11 days after her employment began at the house. The manager said that she was in receipt of a satisfactory POVA 1st check prior to employment commencing but there was no evidence of this on file. Evidence was faxed to CSCI the day following the inspection. All staff were subject to a satisfactory 6 month probationary period. Records showed improvement in both induction and core training provision. Induction training was started on the first day of employment and for two of the three newest employees was completed within 8 weeks of appointment. Staff initially worked on a supernumerary basis for at least 2 weeks after appointment, which allowed time to get to know service users, read care plans and become familiar with policies and procedures. Pendleton Care were beginning to review induction and foundation training with a view to changing to SkillsforCare common induction standards by September 2006. Given the specialist nature of the service, all but one new employee had received training in challenging behaviour and autistic spectrum disorder. In addition, all the team will have attended a course relating to Asperger’s Syndrome by 16.03.06. Staff had also received training in diabetes and epilepsy to ensure they were equipped to meet one person’s specialist needs. Individual staff training profiles were in place but information relating to the number of paid days training provided for all staff was not to hand as this was collated at Head Office. The manager had completed the NVQ level 4/Registered Managers Award and all but one newly appointed staff member had attained NVQ level 2 or 3 qualifications. The new staff member was booked on an NVQ course due to start in September 2006. Staff spoken with all confirmed they received regular supervision from the manager and records held at the house supported this. The number of supervision sessions exceeded 6 per year. One staff member commented that supervision was ‘really good now’ and anything raised with the manager was addressed. With regard to newly recruited staff, supervision was held weekly for the first month at least, longer if the manager felt this was necessary. In addition to supervision, annual appraisals were held. Staff said the manager was open, accessible and provided the support they needed to carry out their jobs. They also commented on her willingness to address issues in order to resolve them for the benefit of service users. Records also supported this view. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 20 Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 21 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 and 42 Service users benefited from a well run home by a manager who provided guidance and support to staff in order to meet service users’ needs. The home regularly reviewed its performance through self-monitoring and consultation, which included seeking the views of service users, care managers and relatives. Care practices within the home promoted and safeguarded the health, safety and welfare of the service users. EVIDENCE: The manager is suitably experienced and qualified. She has successfully completed the Registered Manager’s Award and is currently studying for an MA in Autism. She had a job description which she worked to and kept abreast of current practice through her degree studies, internet access and by attending refresher training courses. Staff commented positively on her willingness to share her learning with them, particularly information pertaining to service users needs. Since the last inspection the manager had recruited new staff and worked with the team to produce a cohesive group who worked well together. Staff Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 22 interviewed said the manager was ‘very accessible’, ‘supportive’ and ‘approachable’ and that she had ‘service users needs at heart’. All staff interviewed had been issued with a copy of the General Social Care Council Code of Practice and staff files confirmed this good practice. The home had an effective quality assurance system which was based on achieving the service’s aims and objectives in general and service users needs in particular. This system included service user surveys and three monthly reviews to which care managers and relatives were invited. Reports of the meetings were sent to participants along with a questionnaire regarding the review, management and staffing of the home. Completed questionnaires were held on file and were seen to record satisfaction with the service. Where specific issues had been raised with regard to individual service users, evidence was available that they had been addressed. The manager also made telephone contact with relatives each week to keep them informed of progress and ask for feedback. Discussion with one relative confirmed this practice which was said to be effective in ensuring views were shared and issues quickly addressed. In addition to the above, service users met monthly with keyworkers to review their individual goals/care plans, and weekly to review activity planners. Representatives of Pendleton Care were undertaking regular audit visits to the home and reports were held in-house and also sent to the Commission for Social Care Inspection. Policies/procedures were regularly reviewed and updated in the light of any changes in the legislation. Supervision was held very regularly and staff meetings were held. All necessary maintenance and associated checks had been made and accident report sheets appropriately completed and filed. Suitable arrangements were in place for the disposal of waste, and COSHH risk assessments were written. A monthly health and safety inspection was undertaken and recordings of the findings made. Fire precautions were also checked on a regular basis. Fire risk assessments were in place and risk assessments had been undertaken with regard to the premises, both in respect of service users and staff. The format of these assessments was being reviewed. Fire drills were held regularly but a record of participants was not always kept. It was therefore difficult to establish whether every staff member and service user had undergone a fire drill within the last six months. One service user spoken with was familiar with the procedure and able to talk the inspector through it. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 23 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 X 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 4 X X 3 X Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 24 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA20 Regulation 13 Requirement The registered person must ensure that the medication policies and procedures are reviewed and implemented. The registered person must ensure that the supply of leave medication is risk assessed and that details of how medication is supplied are recorded. Service users must be issued with a complaints procedure, in a format they understand, which includes contact details of the divisional manager and CSCI. The landing carpet must be replaced and the landing redecorated. Evidence of a safe recruitment and selection process must be held at the house. Timescale for action 24/04/06 2. YA20 13 20/03/06 3 YA22 22 31/03/06 4 5 YA24 YA34 23 19 30/04/06 31/03/06 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 DS0000062677.V269802.R01.S.doc Version 5.1 Page 25 Beech Hill, 230 Spotland Road 1 2 3. Standard YA16 YA20 YA20 Risk assessments should be completed with regard to provision of front door keys. There should be written information describing the use of ‘when required’ medicines. Hand transcription on the MAR should be signed, checked and countersigned. 4 5 YA33 YA35 6 YA42 Staff meetings should be held more regularly. Evidence of the number of paid days training each staff member has had over the last 12 months should be forwarded to CSCI, and the information held by the manager for monitoring purposes in the future. The names of participants of fire drills should be recorded in order to monitor that each staff member and service user has at least one fire drill a year. Beech Hill, 230 Spotland Road DS0000062677.V269802.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Bolton, Bury, Rochdale and Wigan Office Turton Suite Paragon Business Park Chorley New Road Horwich, Bolton BL6 6HG 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 Beech Hill, 230 Spotland Road DS0000062677.V269802.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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