Inspection on 22/01/08 for Beech Hill, 230 Spotland Road

This inspection was carried out on 22nd January 2008.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beech Hill, 230 Spotland Road 30/10/06

Beech Hill, 230 Spotland Road 15/02/06

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 Jenny Andrew Unannounced Inspection 22nd January 2008 09:00 Beech Hill, 230 Spotland Road DS0000062677.V357164.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 Beech Hill, 230 Spotland Road DS0000062677.V357164.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. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 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 Position vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 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. 30th October 2006 Date of last inspection Brief Description of the Service: Beech Hill is a large, stone, semi-detached property, which provides 24-hour care for up to three younger 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 three 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 residents require such a facility. The weekly fees are dependent upon the assessed needs of the individual. No additional extra charges are made. The provider makes information about the service available upon request in the form of a Service User Guide and Statement of Purpose, which are given to new residents. A copy of the Commission for Social Care Inspection’s (CSCI) inspection report is held in the office and is available upon request. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This was a key inspection, which included a site visit to the home. The staff at the home did not know this visit was going to take place. There has been no registered manager at the home for the past nine months. An acting manager has been doing the job and the company is presently advertising for a manager. We looked around parts of the building, checked the records kept on the service user to make sure staff were supporting her well, looked at the way medication was given out and watched how the staff spoke to and supported the person living there. The files of three members of staff were also checked to make sure the right checks were being done before staff started working at the home. In order to obtain as much information as possible about how well the home looks after the service users, one service user, the acting manager and the divisional manager were spoken to. A support worker was also spoken to briefly. Before the inspection, comment cards were sent out to the service user, staff and relatives/advocates asking what they thought about the service. One service user, three staff and two relative questionnaires were returned and this information has also been used in the report. Before the inspection, we asked the acting manager to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what the management of the home feel they do well, and what they need to do better. This helps us to determine if the management see the service they provide the same way that we see the service. Upon its return, it was evident the acting manager had spent time and effort in completing it and as well as highlighting what they felt they did well, they were also aware of what they still needed to improve upon. The Commission for Social Care Inspection (CSCI) has not undertaken any complaint investigations at the home since the last key inspection. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? There was no longer any need to use agency staff, as there was now a full team of staff to support the person living at the house. The requirements made in the last inspection for a new landing and hall carpet to be fitted as well as new window frames had been done. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Beech Hill, 230 Spotland Road DS0000062677.V357164.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 Beech Hill, 230 Spotland Road DS0000062677.V357164.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): 2 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The admission procedure was thorough and service users received a full assessment before moving into the home, ensuring their health, social, emotional and personal care needs could be met. EVIDENCE: Since the last inspection, no new service users had moved in. As the preadmission assessment of the person presently living at the home had been seen before, it was not checked at this visit. The divisional manager said they had received a referral approximately four weeks ago, but after the person had visited the home, met the service user and staff and seen where the house was located, she had decided to look for a placement nearer to where her parents lived. The divisional manager described the organisation’s admission policy, stating that anyone being referred to them would be fully assessed over a period of time. She said it was usual for the initial needs assessment to be undertaken by both herself and the organisation’s behavioural psychotherapist. This assessment would be in addition to care management assessments. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 10 Gender, vulnerability and compatibility with existing service users would be taken into account during the assessment process. The service user would be supported and encouraged to be part of the full assessment process and the carer/advocate’s interests would be taken into account. This thorough assessment process ensures the home can meet the holistic needs of any new service users. Part of the admission procedure was to encourage any prospective service user to visit the house and spend differing amounts of time there over an agreed period. This would enable the new person and existing service users to get to know each other before making final plans to live there permanently. Any restrictions on choice or freedom would be discussed as part of the initial care planning process and agreed with the service user and/or their relative/ advocate. When service users had any particular needs or medical conditions that the staff were unfamiliar with, then either in-house or external training was arranged. The staff training matrix evidenced specialist training had been completed by the staff team, which included Asperger’s Syndrome and autism and an introduction to challenging behaviour. Beech Hill, 230 Spotland Road DS0000062677.V357164.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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Care plans and risk assessments were detailed and contained the right kind of information so that the staff team would be able to care and support people to meet their identified goals. EVIDENCE: Due to the fact the home had vacancies, only one care plan was checked. This contained a wealth of information about the person, including background, personal profile, needs, abilities, communication, daily living skills and health. The plan was very person centred and clearly set out how the person wished to be supported, what her likes/dislikes were, day and night routines and dietary needs. It included goals for her to work towards with staff support. It was evident that emphasis was placed on people using the service being in control of their lives and fully involved in decisions about their day-to-day support and routines. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 12 The front of the care plan file recorded it had been implemented in 2003. From speaking to both the service user and the staff, it was clear it had been updated but this was not reflected on the document. When care plans have been reviewed and updated, this should be recorded. A new initiative had been recently introduced. This was called the “Person Centred Pathway to Independence”. Where goals had been agreed with the service user but she was finding it difficult to achieve them, these were then broken down further into more achievable tasks to work on. The care plan clearly identified these and the three-monthly reviews recorded progress towards achieving them. In some instances, the staff were sharing agreed goals and tasks with the staff at the developmental centre, which the service user attended two or three times a week. Detailed risk assessments and behavioural management strategies were in place and included input from other professionals. These were reviewed on a three-monthly basis. The plan also covered vulnerability and included adult protection safeguards. Information contained in the risk assessments demonstrated the service promoted independence within as safe a way as possible, with action necessary to reduce identified risks being clearly recorded. Whilst all but the most recently recruited staff had done physical intervention training, this was only carried out as a last resort to ensure the safety of the service user, staff or other people. Records showed that no physical intervention had taken place since the last inspection. Due to the fact the home had vacancies, the key worker system was not in use as the service user was having one to one support at all times. She said she liked all the staff and would feel able to speak to any one of them if she was unhappy about anything. From speaking to the service user, it was clear she was being supported to follow her preferred routines on a daily basis and was consulted about any major changes or decisions made within the home. Evidence of this was seen in the care plan, staff communication and handover books and the daily diary. Returned comment cards from relatives indicated satisfaction with the level of support and care the service user was receiving. Beech Hill, 230 Spotland Road DS0000062677.V357164.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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The range of opportunities available for service users to pursue educational, community and leisure activities reflected their diversity, social, intellectual and physical capabilities, thus increasing their independence and self-esteem. EVIDENCE: The home’s philosophy was based around the principles that service users’ rights to live ordinary and meaningful lives should be promoted. From checking support plans and reading weekly timetables and daily diaries, it was clear the staff team had a strong commitment to encouraging and enabling the service user to develop individual skills, both in-house and within the local community. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 14 Care plans recorded detailed individual daily preferred routines and from speaking to the service user and staff, it was evident these were respected. Weekly activity plans were negotiated and agreed with the service user and reviewed at the beginning of each week. Changes were made if the service user decided she did not wish to pursue particular activities. Activities included cycling, shopping, visiting the garden centre, cinema, trampolining, drives out and walks. In-house the service user enjoyed music, watching television, crafts, baking, pampering sessions and watching DVD’s. The acting manager said they were trying to introduce new social activities into the programme. On the day of the inspection, the service user went out bowling with a support worker and on her return, said she had really enjoyed it. Feedback from one returned relative comment card recorded they felt more use could be made of the garden area and that the service user would enjoy assisting with gardening tasks. The acting manager said they were going to get quotes from a gardener for it to be tidied so that when the better weather arrived, it would be ready to use. Service users’ cultural/religious needs were identified as part of the preadmission assessment process and recorded on the support plan. The service user was supported to attend a development centre for either two or three half days per week. These sessions were not compulsory and the service user could choose not to go if she wanted to do something else. At the centre they worked to a planned programme, which included numeracy and literacy skills and there were good working relationships between the centre and home staff. Due to the vacancies within the home, the service user was currently being supported on a one to one basis and feedback from the staff spoken to indicated she had really benefited from this level of support. Notes on the support plan and review recordings identified that staff supported service users to maintain family links. This was also confirmed from feedback on the returned relative questionnaires. Each service user plan recorded significant birthdays so that each person could be supported to send cards and buy presents for their friends/relatives if they chose to do so. Courtesy call records were kept showing the dates when staff had spoken to relatives keeping them in touch with what was happening in the home. One relative questionnaire recorded, “The staff always appear very caring towards her and inform us of any unusual circumstances”. The service user also enjoyed the company of a service user from another house and arrangements were regularly made for them to go out socially together, supported by the staff. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 15 Independence is encouraged and promoted and this was evidenced from diary recordings. Household tasks were currently being worked on and the care plan recorded how the tasks had been broken down into easier steps so that the service user would be able to achieve her goals. The staff were aware of the importance of offering a healthy, varied diet to the service user and the menu recordings showed that a range of fish, meat, fruit and vegetables were offered as well as occasional treats. Likes/dislikes were catered for and the service user said she really enjoyed a “chippy meal”. This was put on the menu once a week and followed a morning of physical exercise. Where nutritional needs were identified, appropriate health care professionals would be consulted. Meal times were flexible to fit in with the person’s chosen routines. The service user was supported to go out with the staff to shop for food at the supermarket and on occasions, meals out were enjoyed. Beech Hill, 230 Spotland Road DS0000062677.V357164.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The health and personal care the service user received was offered in such a way as to promote and protect her privacy, dignity and diversity. EVIDENCE: The care plan recorded what support the service user needed along with her preferred routines. The staff said they followed these, ensuring consistency in approach. There was an all female support team and the same gender staff was appropriate for the service user. She was encouraged to do as much for herself as possible and the staff provided appropriate levels of guidance and support in respect of personal hygiene, whilst respecting privacy and dignity. Progress in this area was monitored with the service user when goals and essential skills were reviewed. The daily recordings also showed achievements in respect of independence Current staffing levels were on a one to one basis, which meant that the service user could go out supported in the day or evening if she wished. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 17 The care plan file included a section on the health care needs of the service user. Recordings showed that over the last 12 months, she had received appropriate checks from a dentist, optician and GP. Should specialist needs be identified, then the person would be appropriately referred. Health care needs were reviewed on a three-monthly basis and any changes recorded. The diary recordings closely monitored changes in mood and behaviour so that any significant patterns could be identified. The diary recordings formed the basis of the staff handovers and this detail assisted the staff in working consistently with her. Evidence in the care plan showed that the person’s weight was being regularly recorded and she was being encouraged to undertake regular exercise. The Annual Quality Assurance Assessment document recorded that medication policies and procedures were in place. Medication was being safely handled. Systems were in place for receiving, administering, storing and disposal of medication and met the current guidelines. Medication administration records (MAR) were up to date. When service user’s visited their family, medication taken with them was recorded which was double signed and dated. When ointment or creams were used record sheets were being completed and when medication that had to be used when necessary (PRN) was given, this was also clearly recorded. If service users were assessed as being able to hold their own medication, this was encouraged. However, where staff administered medication, the consent of the service user and/or their relative/carer was obtained. The good practice of arranging regular medication reviews was noted on the service user’s file. The Annual Quality Assurance Assessment document and the training matrix recorded that all the staff had received training in how to give out medication. Beech Hill, 230 Spotland Road DS0000062677.V357164.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Staff had received training in protection issues, so they would know what to do if they suspected service users were not being properly treated. EVIDENCE: The complaints procedure was included in the Statement of Purpose but only very brief reference was made to it in the Service User Guide. It did not clearly explain what the full process was, nor did it give the contact details of the Commission for Social Care Inspection (CSCI). This shortfall must be addressed. The service user spoken to did however say that she would be able to speak to any of the staff if she was unhappy about anything. Feedback from the returned relative questionnaires confirmed they knew the complaints process. The divisional manager was in the process of improving the quality outcomes for people using their service and had recently drafted an abuse and complaints feedback questionnaire for service users. This included both pictures and words so that service users would be able to understand it more easily. We have had no cause to do any complaint investigations at the home since the last inspection. Whilst a complaints book was in place no complaints had been logged. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 19 Adult protection policies/procedures were in place and staff were not employed to work at the home unless all checks had been done. Inspection of service users’ files showed individual risk assessments were in place for the protection of service users and these were regularly reviewed. From checking the staff training matrix, it was noted that four of the five staff currently working at the home had done protection training as well as physical intervention training. The most recently employed support worker had not yet completed these courses but the divisional manager said this would be arranged as soon as possible. All five staff had however, completed NVQ level 2 or above training which included some elements of protection of vulnerable adults. Beech Hill, 230 Spotland Road DS0000062677.V357164.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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. A safe, comfortable, homely environment was provided for the service user. EVIDENCE: The house was located near to the centre of Rochdale and shops were within walking distance as was public transport. The home is a large, leased terraced house, which has two lounges, a large dining kitchen, three large bedrooms, one bathroom (with shower) and a basement. The office, shower room, staff toilet and a bathroom were located in this area. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 21 Communal areas were, in the main, comfortable, personalised, airy, clean and free from offensive odours. Some of the settees were, however, in need of replacing, although the acting manager said quotes to replace them were in hand. Since the last inspection, a new hall and stairs carpet had been fitted and the window frames had all been replaced. The service user showed the inspector her bedroom, which was well furnished and decorated to her own taste. Her family had bought a lot of the furnishings and fittings for the room. The Annual Quality Assurance Assessment (AQAA) recorded that, at her request, the staff had supported the service user to change bedrooms as, at the time of her moving in, the home had been full and she had not been able to choose her room. From walking around the home, several areas were seen that were in need of a coat of paint and the home would certainly benefit from some re-decoration work. The home was not equipped with any special aids and adaptations as the service user did not require these. An Environmental Health visit had taken place since the last inspection, when a food hygiene book had been left for the staff to complete. Staff said they were not using this for recording purposes as they already had systems in place to show temperature checks of food, cleaning rotas, etc. These were seen during the visit. As previously stated, laundry facilities were situated in the basement. The laundry was clean and tidy with suitable flooring fitted and gloves were available. Liquid soap and paper towels were supplied, although the dispensers were empty at the time of the visit. The acting manager filled the dispensers when this was pointed out. The acting manager said infection control training was part of the health and safety training which all staff had done. Beech Hill, 230 Spotland Road DS0000062677.V357164.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, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The staff team had the collective skills, training and expertise to undertake their roles efficiently and effectively which ensured the needs of the service user were being well met. EVIDENCE: Information recorded in the AQAA showed a good age mix of staff and an all female, white British team of workers, reflecting the needs of the present service user. At the time of this visit, there was only one service user living at the home and they were receiving 24-hour one to one support. No agency staff were being used as there was a full staff complement. One support worker with an NVQ Level 3 qualification had been acting as manager of the home since the previous registered manager had left in April 2007. The team worked well together and as a result the service user was receiving good, consistent support. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 23 The service user spoken to said she liked all the staff who supported her and one of the returned questionnaires said the staff always treated her well and that they listened to her and acted on what she said. The divisional manager was making regular calls to the home to support the staff team and staff morale appeared good. Regular staff meetings and 1:1 supervision were being held and this was evidenced from team meeting minutes and supervision sheets held on individual staff files. The staff communicated well together and a communication book, diary recordings and other documents were utilised at staff handovers. Only one new staff had started working at the home, since the last inspection. She had commenced in July 2007 and, from checking the file, it was seen that the organisation’s in-house induction training programme had been completed. This training did not however, meet the Skills for Care Common Induction Standards. The divisional manager had been working on this but the draft produced did not address the key areas. She said she would do further work to ensure the programme included all the necessary Skills for Care units. This worker had however, completed her NVQ level 2 qualification and completed food hygiene, first aid, medication and moving/handling training. Feedback from the three returned staff questionnaires indicated they felt induction training was fairly thorough. One staff said they felt they received good training in order to be able to do their jobs well. Given the specialist nature of the service, all of the staff had received training in challenging behaviour, Asperger’s Syndrome and autism, as well as Autistic Spectrum Disorder. In addition, of the five staff employed, two support workers had completed NVQ level 3 and three had completed NVQ level 2 training. This meant the home had 100 of staff trained. It was agreed that, in the future, proof of training would be held trained staff. Whilst copy training certificates were in place in some files, in others they were missing. The divisional manager said that the originals were kept at head office and were not always photocopied for the in-house files. Consideration should be given to this as holding copy training certificates would not breech any legislation. There was a rigorous recruitment and selection system in place, which was managed from the head office. All staff files were held there, although some copy records were retained in-house. Previous inspections had identified good practice in the recruitment process. The divisional manager said new staff were given a copy of the General Social Care Council Code of Conduct as part of their induction training programme. The files of three staff were checked. One contained all the relevant information, but the file for the most recently recruited staff did not have a copy application form or references in it. These were however, e-mailed from the head office during the inspection. Criminal Record Bureau checks had been made in respect of all staff. Beech Hill, 230 Spotland Road DS0000062677.V357164.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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The management arrangements in place ensured the needs of the service user were being well met. EVIDENCE: The previous registered manager had left in April, 2007. Whilst the post had been advertised, no appointment had been made to the applicants being unsuitable. The post was being re-advertised. In the interim, one of the support workers who had an NVQ level 3 qualification, had been acting as manager with good support from the divisional manager. From discussion with the acting manager, it was clear she had a clear understanding of the organisation’s values and priorities and was working in a person centred way. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 25 Feedback from staff questionnaires was very positive in respect of receiving the right level of support and all confirmed they received regular supervision. Team meetings were also being held. The divisional manager was visiting the home regularly, as well as completing Regulation 26 visit reports. She was currently in the process of reviewing and updating all the company policies and procedures. Outcomes for the service user had not suffered during the time there had been no registered manager. During the inspection, it was identified that the computer did not have Internet access and the acting manager and staff team were not able to keep abreast of changing legislation. Neither could they use the Commission for Social Care Inspection’s website which has a lot of information on it that managers should be aware of. It is strongly recommended that access to the Internet is available in the house. A quality monitoring system was in place and the divisional manager was in the process of improving this and making it more user friendly. A pictorial complaints and protection questionnaire was in draft format and seen on this visit. Two other questionnaires were also being written with pictures in respect of food and home. Questionnaires were being sent out to families asking about their satisfaction with the service and telephone contact was maintained. Three monthly health care reviews were being done for the service user and regular team meetings and supervision were taking place. Any requirements made by us are always met within the given timescales. The AQAA recorded that all the required health and safety policies and procedures were in place. It also showed that the necessary maintenance of equipment was up to date. The fire book, five year electrical certificate and water temperature testing records were checked and found to be in order. Discussion took place as to whether there was a fire risk assessment in place. The divisional manager said this was currently being written. All the staff had done fire training but from checking the training matrix, it was identified that refresher training was needed for three of the staff. Beech Hill, 230 Spotland Road DS0000062677.V357164.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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 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 4 3 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 27 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. 1 Standard YA37 Regulation 8 Requirement A manager must be recruited so the home will be run in the best interests of the people living there. Timescale for action 31/03/08 Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 6 7 Refer to Standard YA6 YA22 YA32 YA34 YA37 YA42 YA22 Good Practice Recommendations When care plans are reviewed and updated, this should be recorded on the file so that continue to work with up to date information about the service users. Two of the settees needed replacing and some redecoration work was required to make the house a more pleasing environment for the service user. The organisation’s induction training programme should meet the Skills for Care common induction standards. Copy training certificates should be held in-house so that training can be verified during the inspection. The company should provide internet access so that the manager and staff can keep abreast of changing legislation. Staff should receive fire refresher training so they will be clear what to do if a fire occurs. The service user guide should contain details of the complaints procedure so that service users will know how to make a complaint if they want to do so. Beech Hill, 230 Spotland Road DS0000062677.V357164.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Manchester Local Office Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ 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 Beech Hill, 230 Spotland Road DS0000062677.V357164.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. Re-publishing this information is in breach of the terms of use of that website. 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