Inspection on 30/10/06 for Beech Hill, 230 Spotland Road

This inspection was carried out on 30th October 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 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 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 Sue Donovan Key Unannounced Inspection 30th October 2006 09:30 Beech Hill, 230 Spotland Road DS0000062677.V298175.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.V298175.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.V298175.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 Zoë Anne McCall Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 3 residents to include: up to 3 residents 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. 15th February 2006 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 residents require such facility. Fees currently range from £85188.39 to £86818.77 per annum Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four hours on one day starting at 9.30 am and finishing at 12.30 pm and included a site visit to the premises and one hour at head office a week later, this was necessitated because staff recruitment records are kept there. The manager was spoken with on the phone the following day and two staff interviewed by phone. The home had not been told about the visit. Time was spent looking at how staff spoke to and helped residents, looking at paperwork about the running of the home and talking with residents, although this was very brief, talking to the team co-ordinator, the manager, two support staff. Time was also spent looking round the building and reading information on staff files. A detailed complaints procedure is in place. Good practice was noted in that the procedure is now available as part of the resident guide, in a pictorial format with contact details for the commission for social care (CSCI) included. Residents had signed the document. A complaints log was in place. No complaints were recorded. Comment cards showed three relatives all were aware of the procedure if they needed to complain. What the service does well: What has improved since the last inspection? The resident guide, contract and how to complain has been written so it can be understood by everyone, this has been given to, talked about and signed by the residents. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 6 New training is in place for staff so that they can support residents better. Residents have their own files, (a person centred plan) which say what they like doing and staff record good things about residents in a book. Medicines that are taken home are now written down and the sheet signed when they are given. All the electric pieces of equipment in the house have been checked to make sure they are safe. The names of staff that have had fire training are written down with the date the training took place. 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.V298175.R01.S.doc Version 5.2 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.V298175.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good assessments for residents ensuring the service provided is individualised. EVIDENCE: Since the last inspection in February 2006, one lady has moved from the home. The statement of purpose has been altered to reflect the vacancy and changes to the staffing compliment. The resident guide/contract has been produced in a user-friendly format, using large print and pictures. This included information under the following headings; the contract, our promise, support, your support workers, staff will help you with your futures, your views, respect and privacy, agreement, safety and security, money, community services, fire procedure, missing persons, medication and complaints procedure. It was observed that residents had signed the user-friendly guides and residents had their own copy. Two resident files were checked. Care management assessments had been received in respect of both residents. The house assessment documents were Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 9 very detailed and these included information relating to health, history, relationships, specialist needs, communication and limitation to choice and freedom. A system is in place for care staff to report changes in care needs so that a reassessment can be undertaken and evidence of this process was contained in care files. One resident ticked on the “Have your say” questionnaire, she did not feel she was asked if she wanted to move to the house or had enough information about the home before she moved in. The manager said that the resident has been offered an alternative home but had not yet decided. Staff had detailed knowledge of the content of residents assessments and evidence was seen that these were reviewed monthly. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&8 Quality in this outcome area is excellent. The judgement has been made using available evidence including a visit to the home. Resident’s individual needs and choices were respected and promoted within the confines of risk assessments. EVIDENCE: Two care plans were looked at. They contained an extensive amount of personalised and very detailed information about resident’s health and social care needs. Care plans included, background and history, personal profile, statement of independence, imagination and flexibility of thought, diagnosis, medical details, next of kin, in the event of death, other professionals involved, community based activity guidelines and daily routines. The care plans clearly showed how residents wanted to be supported, what they enjoyed and what is important to them. Small details such as extended family birthdays were in the plan and records showed cards had been chosen and sent on important occasions. Staff interviewed showed an in depth knowledge of the care plans Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 11 content. One staff said,” we use logs, care plans and working files every day.” Resident achievements are recorded on a regular basis and charts showed good outcomes for residents. Detailed risk assessments and behavioural management strategies were in place and included input from other professionals. Person Centred Planning with residents has started. Residents have their own books that they write in or add pictures to. These are used in conjunction with the new Learning logs (development plans). The Learning Logs include practical and vocational plans, literacy and numeracy, leisure, personal care and presentation, daily living skills communication and goals and outcomes. Photographs of resident’s artwork were on file. It was suggested that the files could benefit from more photographs of achievements being used; making files more accessible to residents. A key worker system is in place, with each resident being allocated two key workers. Strategies, interventions and goals were reviewed after three months and residents, key workers, relatives and care managers were involved in the process as part of the homes quality assurance plan. Quality assurance files were in place for residents, these included plans for the week and weekly key worker audits. Evidence was seen that staff worked very hard to motivate residents and support them to use their local communities. One resident had recently been involved in shopping for the home. Monitoring charts were kept so progress could be logged regarding health and personal care needs. The team co-ordinator said that residents are offered the opportunity to join key worker meetings and staff meetings but they often declined, staff confirmed that this happened. The manager said that residents had the opportunity to meet staff prior to appointment but did not take part in the recruitment process. A review of all files used would be beneficial to streamline the recording systems in place. A relative said, “We are very pleased with the services, facilities and care provided.” Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgment has been made using available evidence including a visit to the home. Activities and links with the community are good these enrich resident’s social opportunities. . EVIDENCE: Individual daily routines are in place for each resident as part of their care plan. Key workers spoken with knew residents really well and reviewed care plans regularly. Residents complete, with staff, weekly planners; these showed community activities that they took part in. The activities included trampolining, cycling, horse riding, shopping, outings in the car and walks in the local area. A chart is Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 13 used to show if residents have taken part in the activity or have declined. The charts seen showed that recently many activities had been declined and this was evidence of the changing needs of residents at the present time. Within the home residents were involved in crafts, watching DVD’s and listening to music. Artwork was seen in one if the lounges. Staff provide support for residents to book and enjoy special evenings and outings. A chart was seen that had been used to count down the days to a trip to a theme park, which a resident had requested. One resident had not had a holiday for some years; the manager explained that funding was an issue. It was suggested the funding for a holiday be discussed with the funding authority. Staff were trained and risk assessments in place to support residents both in their home and in the community. A card system is used if there is an incident in the community to explain discreetly to a member of the public what is happening and provides a contact number. Residents are assisted to maintain links with their families on a regular basis, if that is what they want. In feedback cards relatives confirmed they find staff are always welcoming and they are able to visit at anytime and see their relative in private. A courtesy call record was kept showing the dates when staff had spoken to relatives keeping them in touch with what was happening in the home. Two relatives said that they are kept informed of important matters affecting their relative. Residents are encouraged to be involved in the daily routines of the house. A chart is used to record what they have been involved , for example helping to cook the meal. Staff where seen to show respect to residents by knocking on doors and saying their name before entering. A member of staff said that one resident receives mail regularly from a relative and, with support, opens her own mail, reads and stores her letters in a special box. Residents have the space within the house to spend time alone or in company. Two lounges, within a large spacious property allows for this. Safety locks are fitted to bedroom doors and a risk assessment was viewed to show why residents do not have their own front door keys. Four weekly rotating menus were used that showed menus are varied and nutritionally balanced. Two choices were planned for each mealtime. A record was kept of the food the residents ate each day and was seen to reflect their individual needs and choices. Dietary advice had been taken in respect of the two residents. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 14 Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this area is good. This judgement has been made form the evidence gathered both during and before the visit to the home. The health needs of residents are well met with evidence of specialist health care accessed to meet the needs of residents. EVIDENCE: The service assists residents to be as independent as possible within the confines of agreed written risk assessments. Assessments care plans and learning logs were seen to contain a lot of information about how residents needed to be supported so they can be involved in the activities they enjoy. An all female staff team supports female residents. Permanent staff have built strong relationships with residents. It was observed that staff manage behaviours that challenge well and were able to calm a situation before it escalated. Triggers and responses to behaviours were documented in care plans. Staff said, “my job is very fulfilling” and “ the girls needs come first”. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 16 It was observed that the residents routines where different. One resident chooses to get up much later than another resident. There was evidence that the resident’s health care needs are regularly monitored. Inspection of files showed weight is recorded twice a month; scatter plots were used to show various behaviours during each day. Exercise was encouraged, documented and reviewed. Residents are provided with the support they require attending regular health care appointments, details of which are recorded. A member of staff was observed ordering medication and arranging an urgent doctors appointment, due to deteriorating health needs of a resident. One doctor returned a comment card, sent prior to inspection, he had no concerns regarding the support provided at the home. Health needs assessments were completed and these were reviewed three monthly by key workers. Policies and guidelines regarding medication were seen. A pharmacy inspection had taken place as part of the last inspection. Recommendations made were implemented. Medicines were being stored safely, with a clear record of medicines received into the home and any returned to the pharmacist. Medication Administration Records were examined and were found to be clear and up-to-date. On one record however one PRN did not show the maximum dose in twenty-four hours, this was immediately written into the record by staff. Medication, by one resident, was regularly declined and this is clearly recorded. Medication when residents visit their family is recorded, was observed on a file, when it leaves the home and when it is returned, this is double signed and dated. A medication record for relatives to sign was observed on a file. All staff responsible for administrating medication have undertaken training. Training records confirmed this. It is now the policy to train all staff in the administration of medication. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the home. The home has a good complaints system with evidence that service users feel that their views are acted upon. EVIDENCE: A detailed complaints procedure is in place. Good practice was noted in that the procedure is now available as part of the resident guide, in a pictorial format with contact details for CSCI included. Residents had signed the document. A complaints log was in place. No complaints were recorded. Comment cards showed three relatives all were aware of the procedure if they needed to complain .One resident had returned a “have your say” questionnaire on which she had marked that she felt staff did not treat her well or listen to what she had to say. It was difficult to check the residents views as she refused to comment on this during the inspection. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 18 An internal abuse procedure was held at the home. The home also had copies of Rochdale’s and Calderdale’s Protection of Vulnerable Adults procedures. Staff had undertaken POVA training and this was recorded on the training matrix. Staff interviewed were aware of the policies and confirmed they had undertaken training. Care plans showed individual risk assessments were in place for residents. Risk assessments assisted staff to support residents appropriately, making them aware of what may trigger a behaviour that may challenge and what might help. Staff monitored residents behaviour, documented and discussed this, one resident has moved to another home, since the last inspection, following clashes in personality. Physical intervention (PI) is used as a last resort. Staff had used PI twenty six times over the last eight months. Only trained staff use PI techniques and all interventions were recorded and incident forms completed. It was observed during the inspection a member of staff supporting a resident, calming a potentially difficult situation. Charts are used to show incidents of aggressive behaviour, both verbal and physical. Incidents are reviewed and discussed and a member of staff said that the team helped each other manage difficult situations in positive way. The behavioural Psychotherapist input was requested as needed and referrals to other services were made via the doctor. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 19 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, 26 & 30 Quality in this outcome area is adequate. The judgement has been made using available evidence including a visit to the home. The standard of the environment within the home is adequate providing residents with a homely place to live but some maintenance is required. EVIDENCE: The home is situated close to the centre of Rochdale town centre. It is in a residential area, on a main road with local shops and public transport nearby. The home is a large leased terraced house, which has two lounges, a large dining kitchen, three large bedrooms, one bathroom and a cellar. The cellar houses an office, shower room, toilet and laundry. The house was homely and comfortably furnished and was clean throughout. A large garden with a decked area and furniture is at the front of the property. The garden is in need of some work. Staff said they spend time in the garden during the summer months and encourage residents to get involved. Some ongoing maintenance is needed; damp was seen in the cellar office, some window Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 20 frames need replacing and the hall and landing carpet were badly frayed and worn. The carpet has been a requirement in the last two inspections and staff said a date in November had been arranged to fit the carpet. Staff said the residents had chosen their own colours in their rooms and these were bright and cheerful, decoration was basic and furnished adequately. One bedrooms was viewed this contained lots of personal items making it cosy and comfortable. The bedrooms are lockable but staff can access them if necessary. Laundry facilities were situated in the cellar of the property and could be accessed without walking through food preparation areas. Impermeable flooring was provided in the laundry. Gloves are provided for staff use. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 21 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 & 36 Quality in this are is good. This judgement has been made using available evidence including a visit to the home and to the head office. The staff team had appropriate training to undertake their roles effectively but the amount of agency staff used does not offer consistency of care to the residents. EVIDENCE: Relationships between staff and residents seemed warm and caring with staff demonstrating a good understanding of residents needs. Staff interviewed were aware of what residents responded to and what they enjoyed. One staff said,” I enjoy my work, my job is very fulfilling”. The service has good recruitment and selection processes. Three staff files were looked at and all three contained proof of identity, birth certificates, copies of qualification certificates and other training completed, two written references, evidence of fitness, application forms (on which gaps in career history were explained), interview notes, induction checklists, contracts and role definitions. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 22 Staff received a structured induction programme that consisted of an induction checklist; this is completed within the first four weeks of employment during weekly supervision sessions, two weeks shadowing experienced staff and familiarising themselves with care plans and other information, and a range of training courses. Completed induction checklists were seen on file and staff confirmed they had completed a period of induction. Samples of training records were examined. The permanent staff team were highly trained and had a good knowledge of the specific conditions of residents. An up to date training matrix showed staff had since the last inspection, completed training in, Challenging Behaviour, Values and Principles of care, Aspergers Syndrome, Physical Intervention, POVA, Health Action Planning, Managing Aggression, Imagination and Flexibility of thought and Sensory Perception differences. Evidence of the number of days training each member of staff had received was seen. Staff said,” Training is excellent”, but added that the current staffing levels impact on the training, sometimes having to be cancelled due to staffing shortages. Training planned included, communication (autism specific), physical intervention refreshers, social understanding and interaction and sensory perception differences. Five permanent staff have attained at least an NVQ 2 qualification with one staff due to complete her award in December. The home currently has a vacancy within the home and the staffing hours reflected this. One manager and six fulltime staff (one is transferring to work in another home) are employed to support the residents. Whilst the rotas showed sufficient staff on duty on most days it was found that the house relied heavily on agency staff to ensure the hours needed were provided. Three contracted staff had left since the last inspection (one dismissed, one transferred, and one resigned) none of these posts had been advertised or recruited to. The rotas showed one waking night staff but in response to the needs of residents a sleep- in has restarted. This was confirmed with staff interviewed. The permanent staff team at the home is currently small and insufficient to staff the rota. Agency staff and workers from another home ensure that the required hours are provided, this creates inconsistency for residents and could be a contributory factor in the increasing needs of residents. One member of staff said,” The girls don’t like strangers”. A review needs to be undertaken in relation to permanent staffing levels and discussed with the funding authorities. Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 23 Staff spoken with confirmed they received supervision and appraisal from the manager and staff files supported this. One staff said,” Supervision is good, the manager is really approachable, she’ll sort things out”. Other staff confirmed that the manager supportive saying,” Anything I ask for is readily there”. “ a good manager”. Beech Hill, 230 Spotland Road DS0000062677.V298175.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 7 40 Quality in this area is good. This judgement has been made from the evidence gathered both during and before the inspection of the home. The home was well managed with good quality monitoring systems in place. In the main the health, safety and welfare of residents and staff are promoted and protected. However some shortfalls were identified which need to be addressed in order to minimise the risk to residents and staff. EVIDENCE: The manager is suitably experienced and qualified. She has NVQ 4/Registered managers award and is currently studying for an MA in Autism at Hallum University Sheffield. The manager has a job description and fulfils her roles and responsibilities. She kept abreast of current practise through her studies, internet access and by attending short courses. She is currently involved in training staff in Sensory perception. Staff commented positively on her Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 25 willingness to pass on her knowledge to them in order to benefit the residents. One staff said,” we get good support, there is strong teamwork”. The home had an effective quality assurance and monitoring system in place, which is based on achieving the services aims and objectives and residents needs in particular. The system includes weekly key worker audit and three monthly reviews, to which care managers and relatives are invited. Reports of the meetings were sent to participants. Telephone contact was made with relatives each week to keep them informed of progress and ask for feedback. The ‘courtesy call’ sheet documenting the subjects discussed confirmed this. Residents meet with staff weekly to review and complete activity planners, and monthly to review there Learning logs and care plans. Records of audit visits made by representatives of Pendleton Care were seen. Supervisions were held and four staff meetings had been held in the last six months, minutes were seen on files. The pre-inspection questionnaire showed that all required health and safety policies and procedures were in place. Random sampling showed Health And Safety maintenance checks had been carried out regarding portable appliance testing, water temperature monitoring and the control of substances hazardous to health. The electrical wiring certificate was not available and appliances failing the PAT inspection had not been removed from the premises. Fire risk assessments were in place. Records of Fire Drills were kept and the fire alarm tested weekly. Staff confirmed they had received training in fire safety. Beech Hill, 230 Spotland Road DS0000062677.V298175.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 3 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 2 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 4 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 X 3 X X LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 4 X 4 X X 3 X Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 27 Yes 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 YA33 Regulation 18 (1)(b) Requirement The registered person must ensure that the employment of any persons on a temporary basis at the care home will not prevent service users from receiving such continuity of care as is reasonable to meet their needs. Specifically the amount of agency staff being used should be reduced and a permanent team employed. The registered person must ensure the premises to be used as the care home are of sound construction and kept in a good state of repair externally and internally. Specifically a planned maintenance programme must include replacement of some windows, a programme of redecoration, replacement of hall/landing carpets and the work to remedy the damp in the office area. Timescale for action 28/02/07 2. YA24 23(2)(b) 30/12/06 Beech Hill, 230 Spotland Road DS0000062677.V298175.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 Refer to Standard YA1 YA2 YA6 YA6 Good Practice Recommendations The registered person should consider reviewing the amount of files/ logs/plans to streamline them. The registered person should consider increasing (with resident’s permission) the amount of photographic evidence, showing outcomes/achievements. The registered person should consider helping residents to choose a short break/holiday; this could be discussed with funding authorities. The registered person should demonstrate that the electrical installation is safe. The registered person should ensure that duty rotas are clearer, with the designation of staff and times of shifts documented. The registered person should ensure that items of electrical equipment that were deemed unsafe during portable appliance testing, are removed YA14 YA42 YA33 YA42 Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 29 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.V298175.R01.S.doc Version 5.2 Page 30 Beech Hill, 230 Spotland Road DS0000062677.V298175.R01.S.doc Version 5.2 Page 31 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!