Inspection on 20/12/06 for Beech House

This inspection was carried out on 20th December 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beech House 22/09/07

Beech House 20/02/06

Beech House 01/09/05

Beech House 01/03/05

Beech House 18/06/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 Beech House 21 Gravelly Hill North Erdington Birmingham West Midlands B23 6BT Lead Inspector Peter Dawson Key Unannounced Inspection 20th December 2006 10:00 Beech House DS0000028592.V324398.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 House DS0000028592.V324398.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 House DS0000028592.V324398.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech House Address 21 Gravelly Hill North Erdington Birmingham West Midlands B23 6BT 0121 382 6163 0121 382 7290 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) Birmingham Focus on Blindness vacant Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (6) registration, with number of places Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Residents must be aged under 65 years Date of last inspection 20th February 2006 Brief Description of the Service: Beech House is a large detached house situated in the Erdington area of Birmingham, and is within easy walking distance of the local shopping centre. Star city entertainment village with cinemas, shops, restaurants and bowling alleys is a five-minute drive away. The home offers accommodation to six residents with sight loss and learning disabilities. Each resident has his or her own personalised bedroom with en-suite bathroom. The home has a large car park to the front with attractive flower borders; the rear of the home can be accessed via a conservatory and is mostly laid to lawn with flower borders and attractive garden furniture. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector on one day from 10am – 5.30pm. A pres-inspection questionnaire was provided by the service and forms part of the information in this report. Five written feedback forms were completed on behalf of residents by relatives and two feedback forms completed directly by relatives. All were received by CSCI prior to the inspection. Residents and relatives expressed positive views about the care provided at Beech House. One relative was unhappy about past events (mainly historical) and known to the service. The inspector spoke to that relative on the telephone and promised that the Acting Manager would contact her directly, or when visiting the home to further discuss some areas of care still giving cause for concern and to ensure that all previous issues raised had been appropriately recorded as complaints. A Social Services Reviewing Officer stated in written feedback “Maxin Kallon (Acting Manager) has been very cooperative during the service user review. She is very organised, professional and exhibits good leadership skills” Written feedback from a Clinical Psychologist recorded satisfaction with the overall care provided at Beech House. All residents were seen, two do not have speech. Two able to give a verbal vies of the home said and seemed happy with the care provided and their daily lifestyles. A regular visitor was spoken to during the inspection and she expressed her total satisfaction with the care provided for her son. She is a regular visitor, staying for several hours and felt that she had a good overview of the care and practices in the home. She said she was kept informed of all events affecting the life of her son and felt confident that there was consistently good care. She has been invited (and accepted) an invitation to join her son for Christmas Lunch at Beech House and will be bringing her mother also who is very close to the resident also. Apart from some areas of staff training – all 13 requirements of the last inspection have been addressed. Some areas that were poor have been improved greatly. Some areas need further development and there are positive signs that this will continue. The weekly fees for care at Beech House are £1,042 What the service does well: The home is spacious and well appointed and there has been redecoration and improvement of many areas. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 6 All residents have a learning disability and have no sight. Two do not have speech but there was observed good engagement between residents and staff using non-verbal communication methods. Residents able to express a view said that they were happy at Beech House and enjoyed the activities provided for them at the providers day centre. What has improved since the last inspection? What they could do better: Nighttime needs and profiles should be established for all residents. All documents required for staff as stated in Schedule 2 of the Regulations must be obtained. Staff training must be provided in mental health awareness and first aid. A Registered Manager must be approved by CSCI to runt he home. All events affecting the welfare of residents must be reported to CSCI Immediate advice must be sought from the Fire Officer in relation to the fire exit from the ground floor bedroom identified. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 7 Consider ways of greater empowerment of residents in relation to their finances. Provide suitable, readily available transport and adequate number of drivers. Many areas of the home need repainting to improve presentation. Consider the repainting/refurbishing of the kitchen area. 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 House DS0000028592.V324398.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 House DS0000028592.V324398.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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The statement of purpose has been updated as required. An appropriate assessment tool is to be used to assess need for a current vacancy. EVIDENCE: The Statement of Purpose required updating at the time of the last inspection. This has now been completed and is satisfactory. A resident admitted in 2005 whose bathing needs the home could not meet. A new assisted bathing facility has been installed as required since the last inspection and although the resident is currently in hospital and not returning to Beech House the bathing facility is usefully used by 2-3 other residents. There have been no new admissions to the home since the last inspection. There is currently a vacancy and enquiries being received for possible admissions. The lesson learned from the above inadequate bathing facilities are fresh in the minds of staff who will carry out a comprehensive assessment to ensure the needs of future residents can be met and of course that they are compatible with the needs of other residents. Beech House DS0000028592.V324398.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Considerable work has been done to improve care planning and risk assessment, this is almost complete. Greater financial independence for residents could be pursued. EVIDENCE: The Acting Manager and Deputy were appointed in November 2005. Care plans and risk assessments were poor and requirements made in previous and also the last report to improve them. Considerable work has been done in this area by the new managers. With the exception of one all care plans have been revised and updated on a new care planning format. There is now a separate file for risk assessments relating to individual residents and all areas of risk which are cross-referenced to care plans. Care plans now provide the required detailed support in relation to each resident. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 11 Two care plans were inspected in detail and included a pen picture for each – “This is me” giving a background history and listing current and future goals. Care plans seen included information relating to: Perceptions, relationships, sexuality, eating & drinking, person hygiene, mobility and health and safety. Risk assessments included assessments for: hot drinks, using the stairs, self harm, eating, choking and evacuation of the premises. Photographs of Key Workers were being obtained. A weekly schedule of activity for each resident has been established. There is a daily report completed for each resident for each of the 2 day shifts. All care plans and risk assessments are now reviewed on a regular basis with a maximum period of 6 months. Night checks are recorded hourly but a written statement of need and protocols should be provided in relation to each resident outlining the night care needs of each person. There are 2 night staff, one waking the other sleeping- in and on call. There has been some use of night agency staff. A recommendation of the last report to review has residents are supported to manage their won finances has not been progressed and a further recommendation is made in this report. – No personal allowances are made direct to residents, all are made to relatives who handle finances on residents behalf. All have DLA payments with implications for transport facilities. This aspect should be reviewed to assess the possibility of greater empowerment/independence of residents. Beech House DS0000028592.V324398.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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Internal and external activities have been developed with resident input. There is much improvement. Some staff need to be further convinced of the work to be done in this area. The Manager is determined to continue the improvements. EVIDENCE: All six residents attend a day service on a full time basis. (Monday to Friday). This is provided for people who are blind or partially sighted by the providers (Birmingham Focus on Blindness) and is a day care facility for up to 85 people. The programmes are activity focussed, residents said that they enjoyed the centre and spoke of the numerous activities they were involved in. They are fully occupied throughout the day and often enjoy just relaxing when they get home in the evening. Activities in the home and access to community activities have previously been poor in this home. A requirement was made in the last report for the manager Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 13 to consult with resident about the programme of activities they prefer. This has been done. Residents meeting have been held and minutes record residents suggestions and choices. Some board and table-top games have been purchased, some seen in operation during this inspection. £300 was spent on craft materials but it is felt that this may replicate some of the activities provided for all residents at the day-centre. Good progress has been made in external visits. An amount of £2,400 was allocated for holidays, residents chose day excursions as a preferred option and there have been much enjoyed outings to Skegness, Lake District, Blackpool, Longleaf and others. These were their choices. Whilst activities in the home have improved the Acting Manager has some difficulty in persuading some staff of the need for a broad and individual need for activities with residents, often on a 1:1 basis often involving just communication. This is being further developed by the Acting Manager. Transport is not readily available. The home do not have a vehicle allocated for their sole use. There are vehicles at the providers day service centre the other side of Birmingham which can be accessed when not in use. In practical terms, only one member of staff is currently able to drive those vehicles (large and require training) – the result is only occasional use of that transport. Taxis are used on some occasions. The question of DLA payments to residents can be linked to this in the home reviewing the need for suitable and readily available transport. The Deputy Manager is on the staff rota 2 days per week specifically to positively pursue the activities provided in the home. Sampling of care plans, conversations with residents and staff indicated that residents relatives, friends and advocates are actively involved in their care. Many have very regular contact with their family and some have regular visits to their relatives homes. This was also confirmed by the visiting parent of a resident seen during the inspection. She is a regular visitor when she spends several hours in the home. She was very complimentary about the care provided at Beechcroft and this was also endorsed in a conversation including her and her son. The weekly menu cycle has been changed involving residents in those changes. A resident spoken to said that the “food was good and he had all the things he liked” There was little evidence of residents being involved in food shopping. This is done by staff on Saturday. Compilation of a food shopping list would be a start in this area. None of the residents are involved in food preparation in any way. Perhaps the home could consider ways of involving residents in these areas taking account of present skills levels and the need for risk assessments. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Risk assessments and the management of epilepsy have improved considerably. Personal support is provided in the best interests of residents and staff support physical and emotional needs. There is a safe system of medication. EVIDENCE: Requirements were made at the time of the last inspection concerning the management of epilepsy and review of risk assessments relating to it. This has been done. A specialist nurse has provided training for staff in epilepsy management and new medication prescribed after review with the doctor. Staff have also had specific training relating to this medication. The results are that risk assessments have been reviewed in the light of changes in the management and prescribed medication for epilepsy. Most residents have diagnosed epilepsy. One has potentially life-threatening seizures which occurred once in 2004 and again in 2006. There is a strict protocol in place for the management of those seizures, which is basically to seek immediate urgent medical assistance but also actions to be taken by staff during and following seizure. All staff have read and signed the new protocols. The person involved Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 15 is going home for 3 weeks at Christmas and management of her condition vital. The home arranged a Best Interests meeting recently to involve the family and set the rules for medication administration and for swift medical attention in the event of a seizure whilst at home. Dependency levels are high in this home. All residents have a learning disability, all have no sight, with the exception of one who has restricted tunnel vision. One resident was recently admitted to hospital having a terminal illness and is to be transferred to nursing care. Due to complex needs one resident chooses to spends a large proportion of her time at floor level when she is at home. She has her own carpeted area (the conservatory) where she can move freely and safely. Two people have no speech. Some have restricted mobility. Three wear head protectors, protecting against falls and self-harm. Two are doubly incontinent and two singly incontinent. One resident has challenging behaviours two incidents earlier this year resulted in him having self-inflicted head injuries. Specialist help was sought and protocols put into place. Staff have all received specialist training in the management of difficult behaviours (MAPA training) involving controlled methods of restraint to avoid self-harm. A very positive feature of this was that the parents of the resident were involved in this training and also received certificates of attendance/competence. Care plans clearly defined the actions required by staff to provide personal care for residents in varying circumstances. It was pleasing to see that a plan was established to facilitate personal expression of sexual needs. Health care action plans have been further developed since the last inspection. The medication system in the home was inspected by the CSCI Pharmacist in February 2006 and a safe system of medication in place. Staff had a good understanding of the clinical needs of resident and actively sought medication reviews with the GP. The system was inspected on this visit. There were no gaps in medication records. Overstocking of paracetamol had been reduced. Medication sheets are booked in and out to the day service centre and medication sent home with residents is recorded in and out. Two staff sign all medication taken/received. All residents have lockable cabinets in bedrooms but there is self-administration only of some creams at this time. All returns to the pharmacy are typed on a list and countersigned by the Pharmacy completing the medication audit. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The opportunities for making complaints have been extended, there are several options open to residents. Referrals have been made under Vulnerable Adults procedures and appropriately investigated. All referrals must be notified to CSCI. EVIDENCE: A requirement was made in the last report for the Acting Manager to explore ways of ensuring the complaints procedure was more accessible to residents. It was felt that most residents would be unable to verbally raise a concern or complaint. This has been addressed by providing all residents with an audiovisual tape in the bedroom outlining the complaints procedure. Additionally Key Workers have 1:1 discussions with residents about the complaints procedures one worker instanced that she asks “Is there anything you don’t like about Beech House”. There are other built-in safeguards to this. All residents have daily attendance at a day centre where behaviours are monitored and issues can be raised. Additionally all residents have visitors. Some go home overnight on a regular basis or even visited weekly. Staff have had training in the Protection of Vulnerable Adults procedures. There have been two complaints of alleged abuse by staff. Both have been dealt with under the Vulnerable Adults Procedures. One referred by a resident, was investigated and found to be untrue – there had been a former false Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 17 allegation by the resident also. The other complaint made by a member of staff (whistleblowing) has been recently concluded following an investigation by the providers which was agreed by the Vulnerable Adults Coordinator. Staff have been interviewed and statements taken the outcome is that there is no evidence to support the allegation. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely, comfortable and safe environment. Facilities are good and redecoration only would improve the presentation of many areas. There is adequate equipment to assist residents in daily living EVIDENCE: Since the last inspection two bedrooms have been redecorated and recarpeted. The dining room was redecorated and re-carpeted prior to the last inspection. The size and layout the physical environment is good. All bedrooms are large, many have double beds and all have en-suite facilities with shower. Most bedrooms were seen and were well personalised reflecting individuality. Rooms are large, bright and spacious allowing good mobility. Many have large windows with good views of the garden and neighbourhood which can not be enjoyed to the full due to visual impairments of the residents. Corridor areas are spacious giving access to the communal areas on the ground floor. There are 2 bedrooms on the ground floor. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 19 Many areas require repainting due to the colour and presentation of the decoration. Colours are mainly definite/dark – repainting would greatly improve the presentation particularly of the ground floor area. The entrance, corridor areas and kitchen would particularly improve the overall impressions of the home. This is recommended. A recommendation of the last report to refurbish the kitchen was made, this is reiterated as a recommendation of this report. Repainting of the kitchen area would greatly improve overall presentation but there is limited storage and work surface space. The seating in the lounge area is being replaced in the near future by the providers. The recommended improvements are mainly cosmetic. The home is well located, spacious, and clean. There is an enclosed private garden area to the rear with adequate seating and used throughout the summer months. There is good and easy access to the garden from the conservatory. A requirement of the last report to provide assisted bathing facilities on the first floor for a recently admitted high dependency resident has been met. A new electrically operated bath installed at a cost of £4,000. Unfortunately the resident it was intended for has been admitted to hospital with a serious medical condition and will be transferred to a nursing home, not returning to Beech House. The new bathing facility has been used regularly by several other residents and is therefore a useful additional facility. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. These outcomes have been improved from poor to adequate since the last inspection. The Acting Manager intends to continue to improve the effectiveness of the staff team. All staff now receive regular supervision. Training has improved the ability of staff to meet residents needs. EVIDENCE: Many areas in relation to staffing have required improvement in this home since the Acting Manager was appointed 12 months ago. A lot of hard work has been applied to achieve some positive results. There has been training in most areas of required statutory training since the last inspection and in some other areas of professional training. There are still some staff who do require training in first aid, communication, epilepsy and some other areas of non-statutory training, but a good programme of training has been put into place during 2006 and this will continue. Training records were poor but there is now a training matrix clearly identifying areas of training completed and those requiring further action. NVQ training continues and is offered to all staff. At this time 75 of care staff have received training to NVQ2 or above. Moving & Handling training was arranged for several staff in Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 21 the week following the inspection. Training had been arranged following a requirement of the last report in Behaviour Management, Epilepsy awareness, and MAPA. The only area of training not provided was in Mental Health Awareness and this needs to be arranged in the future. Many historical staffing issues needed to be addressed. Disciplinary action has been taken and resolved many of those issues. Some staff have left since the last inspection. There are currently 4 staff vacancies, two appointments have been made and presently on induction programmes, shadowing shifts in the home prior to being on rota. Recruitment procedures include applicants working in the 85 place day centre, particularly with residents from Beech House. Written feedback and assessments are made. There have been vacancies on nights which have been covered by an agency with staff who have previously worked at Beech House. There was previously no staff supervision in the home. This now takes place for all staff with a target of at least 2 monthly supervision. Records relating to 2 recently appointed staff were inspected. Appropriate references and POVA/CRB checks had been carried out prior to employment. In relation to a person employed for 4 months there was still no evidence of NVQ qualifications or first aid training claimed by the person. All documents required under Schedule 2 of the Regulations must be obtained prior to employment. Many necessary changes to the staffing group have been made. Further work is needed to enhance and develop the skills of the staff team. The Acting Manager intends to achieve the necessary improvements in skills and training. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Although there is an experienced and effective Acting Manager and application is required for a Registered Manager at Beech House. The health, safety and welfare of residents are promoted in the home. Immediate advice of the Fire Officer is required in relation to an aspect of fire safety. EVIDENCE: The previous Manager resigned in September 2005. The present Acting Manager and Deputy were appointed in November 2005. The Acting Manager was previously a Registered Manager for another organisation and has considerable experience in this service-type setting. A requirement to make application to CSCI to register a manager for Beech House was made at the last inspection. Application was made by the current Acting Manager but further information/evidence was required from her before the application Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 23 could be progressed. She will make further application for approval to CSCI as soon as possible. The Acting Manager presents as competent and has certainly addressed many thorny issues which were necessary to improve the service. She was helpful, open and positive about her plans for the future of Beech House and seemed committed to the further development of the home. Fire records were inspected and all required checks, drills and servicing of equipment had taken place. The Acting Manager reported upon successful fire drills which included residents who cooperated with a swift evacuation of the premises. She is confident of swift and safe evacuation in the event of fire. Contact must be made with the Fire Officer urgently to discuss the door from a ground floor bedroom which leads to the office area, but has a notice defining it as a fire exit, although the door is locked and there is no key readily available. All incidents affecting the lives of residents must be reported to CSCI under Regulation 37. This particularly relates to a Vulnerable Adults referral which was not notified. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 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 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 2 32 2 33 3 34 2 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 3 LIFESTYLES Standard No Score 11 2 12 3 13 2 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 x x 3 2 x Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 25 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. 2 3 4 5 Standard YA6 YA34 Regulation 15(1)(2) 19(1) Sched 2. 18(1) 8(1) (a) 23(4)(a) (b) 22(3)(4) Requirement Night time needs and profiles must be established for all residents. All documents defined in Schedule 2 must be obtained for all staff prior to employment. Staff training must be provided in areas of First Aid, and mental health awareness. A Registered Manager must be approved to run the home. See immediate advice from Fire Officer concerning fire exit from ground floor bedroom door which is locked and has no key. Discuss with relative identified historical and any current concerns or complaints. Timescale for action 31/01/07 31/01/07 28/02/07 31/01/07 21/12/06 YA35 YA37 YA42 6 YA22 31/01/07 Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 26 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 Refer to Standard YA7 YA13 YA24 YA28 Good Practice Recommendations Current systems must be reviewed to ensure residents have greater control of their own finances. Provide suitable and readily available transport with adequate numbers of drivers. Many areas of the home required repainting to improve presentation. Seating in lounge areas need replacing as planned. The kitchen area needs refurbishing/repainting to improve standards. Beech House DS0000028592.V324398.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 House DS0000028592.V324398.R01.S.doc Version 5.2 Page 28 - 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. 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