Inspection on 22/09/07 for Beech House

This inspection was carried out on 22nd September 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beech House 20/12/06

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 Monica Heaselgrave Key Unannounced Inspection 22 And 26 September 2007 11:00 nd th Beeches (The) (Seven Kings) DS0000028592.V348082.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 Beeches (The) (Seven Kings) DS0000028592.V348082.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. Beeches (The) (Seven Kings) DS0000028592.V348082.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 post Care Home 6 Category(ies) of Learning disability (6), Sensory impairment (6) registration, with number of places Beeches (The) (Seven Kings) DS0000028592.V348082.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 December 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 people with sight loss and learning disabilities. Each person has his or her own personalised bedroom with en-suite bathroom. The Home is large and spacious enough to meet the needs of the people accommodated, it is well maintained and comfortably furnished. People have the specialist aids and equipment they need to support them. 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. The Fee level for the Home was not known at the time of completing the report. Items not covered by the fee are not known. Beeches (The) (Seven Kings) DS0000028592.V348082.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 on a Sunday, was unannounced and involved one inspector. The inspector met all the people living at the Home, except for one who was on holiday, and spent time observing support and interactions from staff. Both the breakfast and Sunday dinner mealtimes were observed. The inspector looked at all the communal areas, bathing facilities and peoples’ bedrooms. Records about peoples’ care and health, and their medication were looked at. Health and safety records were also assessed. Information relating to staff training and recruitment was not looked at, as the senior staff on duty had no access to this. The information looked at was used to determine whether peoples varied needs are being effectively met. Two people who live at Beech House were identified for close examination this included reading their care plans, risk assessments daily records and other relevant information. This is part of a process known as “case tracking” where evidence is matched to outcomes for people who use the service. The manager failed to complete an AQAA (annual quality assurance assessment). The AQAA tells CSCI about how well the Home is performing and achieving outcomes for the people who live in the Home. Information from the AQAA is used to help inform the inspection process, supporting evidence would have been useful to illustrate what the service has done in the last year, or how it was planning to improve. A reminder letter was sent to the Home explaining that it is an offence not to return the AQAA, the Commission may consider taking enforcement action on this matter. This remains an outstanding requirement. Reports of accidents or incidents reported to CSCI involving people using the service were looked at, as part of the planning of the inspection. In the absence of the AQAA Questionnaires were not sent out to people living in the Home or their relatives. What the service does well: The staff members on duty knew peoples needs and were caring and responsive towards them. People living in the home said, “staff is nice,” “ they help me,” “I can talk to the staff”. People said they liked their home, and they are close to shops, pubs and places to eat out so they can go out if they want to. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 6 People have their own rooms with en-suite bathing facilities. One person said “‘I love my bedroom it is big and I have room for all my things”. People are supported to keep in contact with their family and friends and the importance of these relationships is recognised by staff. What has improved since the last inspection? What they could do better: The acting manager must ensure that the annual quality assurance assessment is completed and returned to the Commission. The information this provides is important to illustrate what the service has done in the last year, or how it is planning to improve. Peoples’ needs must be looked at more carefully before they move into the Home, so that staff can plan the care and support that people may need. There must be a detailed care plan in place for all of the people living in the Home, so that staff know how to meet people assessed needs, and support them in the things they wish to do. This should clearly identify the care and support people need. Where people need specialist support so that they do not hurt themselves, or others, the care plan must show that specialist advice has been sought, and what steps are to be taken by staff to support the individual. The activities people enjoy should be explored further, and written into their care plan. There needs to be means of measuring how often these opportunities are made available for them to ensure they have a fulfilling lifestyle. The daily reports could be improved to show how people make decisions, what activities they choose, and how they respond to events. This information could help with future planning for the person. Risk assessments must be followed consistently so people are safeguarded from harm. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 7 Health action plans need to be introduced. These are plans that tell people what they must do to stay healthy and include information about any particular steps to be taken to keep a person well. These must provide staff with clear information to follow. Arrangements must be in place so that all staff has training in adult protection and whistle blowing procedures. This is to ensure that people in the Home are not at risk of harm or abuse, and that staff know what to do if they suspect abuse. The complaints procedure and other important information must be made available in a format suitable for the people living in the home so they know and understand how to make a complaint. There are some minor improvements needed to make sure the premises are comfortable and safe for the people who live there. The dining room chairs need to be more robust and some redecoration in bright colours would be more suited to the age group currently accommodated. Staff must receive training in first aid, safe medicine handling, Epilepsy, and MAPPA training, (training in safe restraint techniques), so they know how to support people and understand their individual needs. The staffing situation must be reviewed to ensure there is sufficient staff on duty at mealtimes to ensure the needs of people are being met. Many changes to the staffing group have taken place the manager needs to complete a staff training needs audit to ensure that staff have the required training, skills and knowledge to meet people needs. It is important that the staff vacancies are recruited to and that senior staff have the experience, skills, training and qualification to undertake this role. This will help the service to develop better outcomes for the people living at the Home. Previous information about this service indicates that appropriate safety checks are carried out, before staff starts to work in the Home. This ensures that people living in the home are protected from potential abuse. These records must be available for inspection. It would be nice to see more comments from the people living in the Home in the monthly report. This would mean the owner has a good oversight of the things that need improvements and provide an opportunity for people who live there to talk about things that are important to them. To protect the safety of people living at the Home there must be a current gas safety certificate to show the gas supply is safe. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 8 Fire drills must take place regularly and at least every six months so that staff working in the Home knows how to safely support people in the event of a fire. The fire alarm must be tested every week to make sure there are no problems with the system that might affect the people living in the Home. The home should have a suitably qualified and competent manager in post. This will ensure someone is overseeing the day-to-day running of the home and that it is run in the best interests of the people living there. An application should be submitted to the Commission. 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. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 9 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 Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2, & 4.Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People and their representatives do have information about the Home they live in, but this needs to be developed into a format more suited to the needs of blind and visually impaired people. This would make it is easier for people to access information and help them understand the terms and conditions of their residence. The assessment of peoples’ needs before they move into the home is not comprehensive enough to ensure that the person’s needs, can be met. EVIDENCE: Beech House has a Statement Of Purpose and Service User Guide, which provide Information about what service can be offered. These were on display in the hall of the Home. The information was provided in a standard format. Beech House provides a residential service to people who have a learning disability and sight impairment some of the people who live there are blind. Staff on duty was unaware if attempts had been made to produce this information in a format more suited to the needs of the people who live at the Home. The inspector spoke with the manager at a later date, as he was not available at the time of the visit to the Home. He acknowledged that these documents Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 11 need to be reviewed and appropriately reproduced in a format suited to people who are visually impaired, for instance in audio. There needs to be a system in place to show how people are helped to understand how the home is organised and run and the facilities and services available to them, this will give them more opportunity to make an informed choice to move in or not. People’s needs should be assessed prior to admission so that the Home can be sure it is an appropriate placement for them, one that can meet their specialist needs. Beech House has had recent staff and management changes and it is unclear how much this has disrupted the usual procedures. The previous inspection reported that shortfalls in assessment information had led to a person being admitted whose bathing needs the home could not meet. Following this the service arranged for a new assisted bathing facility to be installed, and this was done. This highlighted the need to have comprehensive assessment procedures in place to ensure that the needs of prospective people new to the Home, could be planned for and met. However there still appears to be shortfalls in developing and maintaining a comprehensive assessment to ensure that the needs of people referred to the service, are assessed in full before a placement is offered. It indicates that practice in this area is not always consistent or well applied. There is currently a vacancy and daily records looked at showed that introductory visits are taking place for a person who is hoping to move into Beech house. It was positive to see that prospective individuals are given the opportunity to spend time in the home. The daily records for the person currently being introduced to the Home were looked at. Some of the entries made in the records by staff, clearly indicate that this persons’ needs and abilities differ from what the original referral and assessment information said. Staff have expressed in their recordings, concerns about safety, particularly at night and especially in relation to the use of stairs and possibly going out of the Home through the front door. It is very worrying that these issues were not identified prior to introductory visits taking place. This leaves staff unaware of the potential risks to the person concerned, and at a disadvantage in planning for them. This was discussed with the current manager who has only been in post since August. The manager said that assessment information passed to them did not alert staff to these issues. He said that appropriate risk assessments are being devised to ensure that staff knows how to support the person, and minimise any risks. The manager must review the assessment process to identify why this information was not available, and to ensure that in future a comprehensive assessment of need is available and that there are ‘no surprises’. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 12 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 adequate. This judgement has been made using available evidence including a visit to this service. Care plans and risk assessments do not fully demonstrate how staff meet peoples assessed needs and reduce the risks they may face. This may mean that people are not provided with the care and support they require. Risk assessments must show that the risks people face, are well managed. EVIDENCE: Two people were identified for close examination. This included reading their care plans, risk assessments daily records and other relevant information. This is part of a process known as “case tracking” where evidence is matched to outcomes for the people who live in the Home. Care plans seen included a pen picture for each person – “This is me”. This gave a nice profile of the individual and contained information personal to them such as ‘I like music, people to talk to me I can understand what is being Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 13 said.’ ‘Don’t be alarmed if I touch your face and hair this is how I get to know you.’ The care plans had information about the person’s likes and dislikes and things that are important to them. Care plans included information relating to relationships, sexuality, eating & drinking, personal hygiene, mobility and health and safety issues. There was also a weekly schedule that outlined the activities the person does on each day this helps to keep a routine, which for some people gives them a degree of structure. The individual care plans had some detail as to how staff should support people. This was linked to the risk assessment. For instance one showed what preventative steps had been taken to minimise the risk of harm in the persons’ bedroom, such as padded corners, two way listening monitor, and the frequency of night time checks. There was little information as to the aspirations people may have. Such as the development of self help or independent skills people had or how they are supported to maintain or develop self-help skills. There was information on one file that showed a parent had provided information as to the existing skills of the person living in the Home, but there was no evidence that these opportunities are made available, they had not been included in the care plan. Care plans lacked measurable goals and this makes it difficult to measure any progress. One person told the inspector that he no longer enjoys going to the Day Centre because the member of staff who used to support him with this has left the Home and he misses her. There was no information on his file to show how he was being supported with this or address his needs in a person centred way. The people who live at Beech House need person centred support plans that will meet their individual needs. Discussion with individual staff and the people who live in the Home showed that some decisions and choices are made by the people who live there, for instance people are consulted on what activities they would like, and what they would like to eat. One person told the inspector he had been on holiday but he couldn’t remember where. Care plans did not reflect decision-making. For instance how decisions are made in relation to peoples’ finances. No personal allowances are made direct to the person living in the Home all are made to relatives who handle finances on their behalf. The service needs to consider how the care plan is presented. This needs to be in a format suited to the needs of blind and partially sighted people who also have a learning disability. Staff need to make the process interesting and use a variety of ways to help individuals make a worthwhile contribution this could be achieved via the key worker system. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 14 Daily records were available for all of the people who live at Beech House. These were brief in their detail and repetitive. They do not include response to care or how decisions are made. Most of the entries refer to personal care routines and what activity the person has been involved with such as ‘listened to the radio’ ‘meal out’ ‘shopping for clothes.’ Some entries refer to behaviour that challenges such as ‘kicking staff’, ‘kicking staff and agitated.’ It is advised that these should be developed so that people’s care needs can be fully monitored through their care records. For instance the behavioural support plan should be in place to guide staff on the steps to take in response to persons behaviour, the daily report should then specify what staff did, whether it worked and how the individual responded to it. This will ensure that the system promotes the use of the care plan and risk assessment so that the outcome for the individual is that there is continuity of care. This was discussed with the acting manager who said that a new daily report format is being produced. This will have prompts for staff so that they are aware of the type of information that is required to be recorded. The care plans seen were reviewed in April and September 2006. It was not apparent that these had been reviewed recently. The contribution of parents and external professionals was evident and the person for whom the review was taking place was present or a reason stated as to why they were not invited to the review. Whilst there is a format for care planning and review there are shortfalls evident. The plan includes basic information necessary to deliver the persons’ care but is not detailed or person centred. It does not include reference to an individual’s particular needs such as how they keep safe, their goals and aspirations, their skills and abilities and how they make choices in their life. It does not focus on how individuals will develop their skills or consider their future aspirations. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 15 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): 13, 14,15 &17. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Peoples varied and individual lifestyles are not being fully met. Systems must be developed so that people can make more meaningful choices about their lifestyle. EVIDENCE: There are five people currently living at Beech House all of whom attend a day service 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, people living at Beech House said that they enjoyed the centre and meeting their friends there. Activities in the home and access to community activities have previously been poor in this Home. Improvements had been made at the last visit to the Home. A programme of activities was established to reflect the choices of the people Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 16 who live at Beech House. Funds were allocated to purchase craft materials, board games and fund external visits. An amount was allocated for holidays, and people chose day excursions to Skegness, Lake District, Blackpool, Longleaf and others. This year some people spoken to said that they have meetings to discuss their activities and that recently they have had several day trips out, they also went to the theatre, and go out regularly for lunch. The daily reports were looked at for an eight week period these showed one person had two days out but it didn’t say where to, one shopping trip, and one meal out. The rest of this period consisted of in-door activities and these were ‘pedicure and manicure’, ‘listening to the radio’, ‘dancing’, and two ‘walks in the car park’. The records lacked detail about how the decision was made and also how the person responds to the activity; if this information is recorded it could help with future planning for the person Some people require a high level of staff support to engage in suitable activities in the home and the local community. It must be clear how people are consulted about the range of activities and leisure pursuits provided within the Home and the local community particularly for those who are dependent on staff support. Staff needs to be more proactive and aware of the need to support people to develop their skills, including social, emotional, communication, and independent living skills. Some people are asked the choice of daily activity, for instance one staff member asked ‘ Do you want your music on’, but this process could be improved. Staff appear very caring and interact in a positive way but there was little observed in the way of encouraging people as an individual, maybe to do some tasks, make a choice where to eat their meal, when to leave the table. It would be nice to see that where able, people are encouraged in day to day tasks such as taking cups and plates to the kitchen, washing up and wiping the tables. One member of staff was observed to support a person wiping the tablemats, and this seemed to be a ‘surprise’ to the staff as they all commented upon it. There needs to be a system for checking that the daily routines and choices are in deed led by the people who live at the Home. This would promote individual independence and the right to live in a flexible environment where their choice of routines and activities are met when possible. People using the service need to be given the opportunity to take part in a variety of activities in the community. Staff should gather information on community based events and try to make individual arrangements for people to attend. Transport is not readily available. The home does not have a vehicle allocated for their sole use. In practical terms, trips out depend on both a vehicle and Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 17 driver being available. The current acting manager has taken people out on a regular basis and planned transport for trips. Taxis are used on some occasions. The use of peoples’ DLA payments may provide better independence and choice for individuals wishing to pursue activities that generate a transport cost. The Home welcomes visits from people’s family and friends and details of family contact is in their care plan. The food in the home is of satisfactory quality, well presented and meets the dietary and cultural needs of people who use the service. The food log was well maintained and gave an overview of the type of foods consumed, this is important where individual people may need support in maintaining their nutritional intake, and can help staff to plan meals. Staff were supportive to people who required assistance although the availability of staff was compromised. One staff member was in the kitchen cooking and serving the meal, one staff member was at the table supervising three people and another staff member was seated away from the table supporting another person. There were occasions when people did not have full support. This is worrying as one persons’ risk assessment relates to the risk of choking. The staff member was having difficulty trying to give support to three people at the same time. These arrangements must be reviewed. Lots of comments were received from the people who live at the Home regarding the food, ‘I like the food, and X is a good cook.’ ‘Yes I sometimes have my favourites.’ ‘Sometimes we go out for meals and I like that.’ ‘The staff know I don’t like eggs so they don’t give them to me’. Some opportunities are available for people to be involved in food shopping. People are not actively involved in the preparation of meals or drinks. It would be nice to see more focus on individuals, recognising their potential in this area and taking account of present skills levels and the need for risk assessments. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 18 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 adequate. This judgement has been made using available evidence including a visit to this service. People are supported to access health care professionals. Health needs are monitored and appropriate action taken. The home is generally able to provide the aids and equipment recommended, but more attention needs to could be given to the records relating to health care, and the interventions in place to ensure peoples safety. EVIDENCE: Dependency levels are high in this Home. All of the people who live there have a learning disability; all have no sight, with the exception of one who has restricted tunnel vision. Some people have no speech, restricted mobility, and are incontinent. Some of the people have diagnosed epilepsy. One has potentially life-threatening seizures Three people wear head protectors, protecting against falls and self-harm. One person has challenging behaviour and there have been incidents earlier this year resulting in self-inflicted head injuries. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 19 Peoples personal appearance was good and indicated that they receive good support to attend to their personal care needs. They wore clothing appropriate to their age, and personal needs. Care plans had some details of people’s personal care routines and preferences. Some of the people told the inspector ‘staff are nice they help me get dressed and have a bath’ ‘I like to have a sleep in the morning and staff let me do this.’ ‘Staff take me shopping for clothes, I like to go to my own room and listen to my music’. People living in the Home are supported to access a range of health care professionals this was reflected in the daily records, the diary and the communication book. Much of this information is duplicated and not easy to track. Whilst it does appear that people are supported to access a range of health care services such as the dentist, G.P. Psychiatrist, nurse, and sight and hearing clinic, this information needs to be collated and put into a Health action plan (HAP). These are a personal plan about what a person needs to stay healthy and what healthcare services they need to access. There was information to show that the specialist Epilepsy nurse had been contacted regarding the Epilepsy protocol and to arrange staff training that would enable staff to follow the protocol. On the day of the visit the staff on duty had not done this training. The training relates to administering medication but staff cannot do this unless they have been certified as competent. There has been a high turnover of staff and some staff now needs this training. The staff on duty was able to describe the emergency procedures to obtain medical help, and this was in line with the protocol. The bedroom of one person reflected that the equipment needed by the person was evident, this included incontinence supplies, hoist and wheel chair. The bedroom was laid out in a manner that would protect the person from injury during a seizure this included the use of an additional mattress at the side of the bed to minimise falls. Staff said they had training in manual handling to support them in the competent use of hoisting equipment, but training records were not looked at, as they could not be accessed. It was not confirmed that all staff had done training in managing incontinence. One person has a tendency to self-injurious behaviour. It was good to see that his bedroom has been padded at wall corners to minimise the risk of head and facial injuries. There is a two-way intercom so that staff can monitor the bedroom without intruding. Specialist help had been sought and protocols put into place to help staff to support this person appropriately. This included staff training in the management of difficult behaviours (MAPA training) involving controlled methods of restraint to avoid self-harm. However the recent staff turnover has meant that some staff has not done this training and as such cannot use the restraint methods. On the day of the visit none of the three staff had done this training. This was discussed with the acting manager who Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 20 said this training has been arranged, some difficulties had arisen with one staff member cancelling training, but this was being addressed. It is important that the staff team all complete this training so that they can respond to the needs of the person. The daily records for this person indicated that there have been several incidents of challenging behaviour; there was no record of an intervention plan. This was discussed with the acting manager who said that a referral had been made to the Behaviour Support Team so that a proper assessment of needs can be made and an intervention plan drawn up as to what staff should try to do to minimise the behaviour. Some people wear protective head helmets to protect them from falls or selfharm. There are risk assessments in place stating these are to be worn. During the morning when coming to the breakfast table two of the people did not have their helmets on. Both the staff on duty, and later the manager, were asked about this. It is concerning to note that where risk assessments are in place, these may not always be consistently followed and could place people at risk of harm. The risk assessments must be clarified to the staff team so that everyone is clear of the expectations. Where appropriate some people had eating and drinking guidelines. These had been developed for staff to follow to ensure that the person does not choke. There were some concerns observed at the lunchtime meal where one member of staff was having difficulty in trying to supervise three people at the same time. This led to occasions when the person was ‘rushing’ their food and filling their mouth. The risk assessment must clearly specify how many staff is required to meet this persons needs during meals. Where it is necessary for one to one support, then this must be clearly specified to ensure the safety of the person. Mealtime arrangements must take into account people assessed needs. The staffing situation must be reviewed to ensure there is sufficient staff on, at peak periods to ensure the needs of people are being met. It may be that the service wishes to consider domestic posts so that care staff is free to provide direct care and supervision to the people who live at Beech House. Where indicated in their profile some people have records relating to their bowel movements. It was good to see that where the daily record said someone seemed constipated, this had been followed up. In the main the healthcare needs of people are known but this information should be in the Health Action Plan so that anyone looking at it can see clearly what needs to be in place to keep the person safe and healthy. This will also ensure that there is consistency in meeting needs. This was discussed with the acting manager who said that a new format for a ‘Health Action Plan’ was being introduced. The introduction of these will ensure that the personal healthcare needs of people are clearly recorded and give a comprehensive overview of their health needs. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 21 Medication is secured in a locked medical cupboard in the office. None of the people have been assessed as being able to take their own medication. The medication administration charts were looked at and were well maintained. The staff member dispensing medication on the day of the visit was able to give a good description of individuals’ health needs, the medication they had and how it is dispensed. There were no staff drug audits seen which would demonstrate staff competence in medicine management. Staff’s training records were not available to show how many staff had done training in the safe management of medicines. The two staff on duty on the day of the visit had not done accredited training in this area; one had done ‘in-house’ training. This was discussed with the manager who was unaware that the training done by this staff member was not accredited; this might indicate that staff records are not a reliable source of information in this area. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 22 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 adequate. This judgement has been made using available evidence including a visit to this service. The recent staffing difficulties have led to a high turnover of staff and a depleted management team. These changes could compromise the ability of the Home to protect people from abuse and may increase the risk to people living in the Home. EVIDENCE: A requirement was made in the last report to explore ways of ensuring the complaints procedure was more accessible to people who live at Beech House. People who live at Beech House would be unable to verbally raise a concern or complaint. The manager said that several documents are being reproduced in audio to enable people to access them more easily. This would include the complaints procedure. CSCI have received no complaints about this service. The complaint log is being maintained as required. The adult protection policy had been seen at previous inspections to the Home. There has recently been a high turn over of staff and this could mean that some staff has a limited understanding or training in this area. Discussion with the senior staff showed that any concerns brought to them are referred to the on-call acting manager, this indicates that those working in the senior position are not experienced in managing such situations and this could compromise the safety of the people living at Beech House. All staff and essentially senior Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 23 staff must be familiar with the guidance so that they can act on the suspicion of abuse. There are some built-in safeguards, which help to protect people who live in the Home, all have daily attendance at a day centre where behaviours are monitored and issues can be raised. Additionally people have visitors. Some people go home overnight on a regular basis. The inspector was unable to establish if staff had training in the Protection of Vulnerable Adults procedures. These records were not available at the time of the visit, as the senior staff on duty, did not have access to staff information and files. There has recently been a concern regarding an injury to a person who lives at Beech House. This was referred under the Vulnerable Adults Procedures. The outcome of this was that it was not upheld. Links with external agencies are known and the acting manager has shown an understanding of safeguarding procedures and how they work. Some people living at Beech House may require interventions designed to protect them from harm. Two staff spoken to had an understanding around restraint issues. They were able to describe the limitations concerning agreed restraint techniques, but had not had the training to allow them to implement these procedures. This training is important as it is focused on keeping people safe. The key concerns in this outcome area are that the senior staff are not qualified, or experienced in managing this aspect of the service. The staff teams training needs are not evident, as records could not be accessed. The acting manager should seek to demonstrate what attempts are made to support the people who live at Beech House, in accessing and understanding the complaints process. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 24 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): 24,25,27,28 & 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a physical environment that is appropriate to the specific needs of the people who live there. There is a range of specialist aids and equipment to meet the needs of the people who use the service. The home is a pleasant, safe place to live. Some minor improvements to decoration and replacement of furniture would ensure people who live at the Home have furnishings appropriate to their needs. EVIDENCE: The home meets all the required minimum physical standards. The décor showed little sign of wear and tear, although the colour scheme did not reflect that of younger adults. Colours in some areas were dark, particularly the entrance hall. There are six bedrooms. Bedrooms were spacious well- equipped rooms with en-suite facilities. All the bedrooms are large, many have double beds and all have en-suite facilities with a shower. Most bedrooms were seen to be Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 25 personalised reflecting individuality. It was good to see that the gender of the person is considered when choosing quilt covers and curtains. Rooms are large, allowing good mobility, and there is room for staff to use hoists and equipment to support people. Corridor areas are spacious giving access to the communal areas on the ground floor. This is important for people who require a wheelchair, and for people with visual impairments to move around safely free from obstacles. There are two bedrooms on the ground floor, which provides better access for those who have difficulty with the stairs. The people who live in the Home were positive about the facilities, one said ‘I like spending time in my room, it’s comfortable and I have the things I like in it.’ The new seating in the dining area is not appropriate to some peoples needs, the chairs are not robust and were seen to be unstable when people were rocking, there are no ‘arms’ to the chairs and they are quite difficult to move back from the table, two individuals seemed to be struggling with this. Assisted bathing facilities are available this includes an electrically operated bath, which enables staff to support people who have high dependency needs. There is an enclosed garden to the rear with seating; people who live at Beech House said they enjoy the garden. A conservatory provides an additional area for those who like to enjoy floor space. The home was generally clean and tidy. It is a large building and staff was seen to be doing cleaning tasks during the time they cared for the people who live there. It is important that the time spent on domestic tasks does not impinge on the time available for direct care of the people who live at Beech House. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 26 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, & 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People are supported by staff that know and care about them, but it is not evident that there are sufficient staff numbers to meet peoples’ assessed needs. The importance of staff training is recognised but the recent high turnover of staff means that there are gaps in the training programme. EVIDENCE: The people who live at Beech House made several positive comments about the staff that care for them; ‘I like the staff, especially X she talks to me and takes me out.’ ‘Staff take me out for lunch at the pub and sometimes shopping, I like the staff’. ‘Staff are kind, X makes me laugh’. Staff interaction with the people who live at Beech House was positive, they were tactile and responsive to individuals and there was a regular level of friendly communication. Staff prompted people where this was needed, and supported them in their interaction with the inspector. There is a nice, friendly and relaxed atmosphere at Beech House. Many areas in relation to staffing have required improvement in this home. In the previous inspection visit in December 2006 it was noted that some improvements had been made such as the effectiveness of the staff team, Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 27 regular staff supervision, and staff attending training courses to improve their ability to meet the needs of people living in the Home. Many historical staffing issues had been addressed, and disciplinary action had been taken to resolve some of these concerns. The overall outcome had improved from a poor to an adequate outcome. In the last few months there have been many staff changes. The manager and the deputy left recently, one member of staff was dismissed and one staff member resigned. Currently, the deputy and three senior posts are vacant. These have been advertised. A new manager commenced working in the Home in August. Staff rotas were looked at and showed that on most occasions three staff are on duty, the manager is working a number of ‘cross shifts’ to fill gaps, several staff work shifts on a casual basis to make up the staffing levels. Beech House does not have a full management team. Observations made on the day show that there is a lack of experience in this role. The senior was struggling to extract herself from a situation she knew was not appropriate. The manager recognises that due to the turnover of senior staff in the Home, shift leaders are taking on a level of responsibility they are not familiar with. There is an on-call back-up for seniors to support them, but it is not an ideal situation. It is important that the new recruitment of senior staff have the experience, skills, training and qualification to undertake this role, to ensure that there are good outcomes for the people living at the Home. Further observations highlighted the need to review the current numbers of staff on duty. The care staff provides care and support to the people who live at Beech House and they also have cooking and domestic tasks to do throughout the Home. The inspector was made aware that tasks are delegated between shifts so that such tasks as laundry and hovering can be done at points in the day when it is less busy. However as stated previously there is a need to ensure that staffing levels at mealtimes are consistent, and in line with the assessed needs of the people who live at Beech House. The manager must review the number of care staff on duty. Consideration should also be given to the employment of domestic staff that could support the role of the care staff; this will ensure better outcomes for the people living at Beech House. The people who live at Beech House have specialist needs, these relate to their learning disability, sight, challenging and self-harming behaviours, and life threatening Epilepsy. The inspector was not able to establish the training undertaken by the staff team, as training records could not be accessed. The Annual Quality Assurance Assessment (AQAA) was not completed and returned to the Commission. The absence of this information hindered the judgements that could be made regarding staff training and recruitment. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 28 Discussion with the staff on duty did highlight gaps in their training, and competence in meeting the needs of the people being cared for. One member of staff who was the ‘senior’ was administering medication, when asked about training she said she had done her training in ‘safe medicine handling’, however this was ‘in-house’ training, and not the external accredited training that equips staff to administer medications safely and competently. This staff member had been working in the home for seven months. This was later discussed with the acting manager who was surprised because he said the staff record showed she had done this training, but it did not specify the training was ‘in-house.’ This indicates that the training record is not a reliable one. The inspector was concerned that none of the staff on duty had undertaken MAPPA Training, (a training course to support staff in safe techniques to be used to prevent a person from harming themselves). The daily reports for one person living in the Home showed frequent occasions when staff had described ‘challenging behaviour’. There was no record to show what strategy was in place to manage the behaviour, what staff did to minimise it or how the person responded to staff intervention. The incident and accident reports were looked at and the ‘body maps’. These records showed that some injuries had occurred to one individual who is known to self-harm and exhibit challenging behaviour. The cause of the injuries was recorded as ‘unknown’. The risk assessments in place for this person did not show that advice had been sought from the behaviour support team to support the person who self harms. The absence of this guidance for staff to follow, and their lack of training in managing these behaviours could potentially mean that the individual is not supported in the appropriate way and could be exposed to unnecessary risks. This is concerning. Staff does not have the skills, guidance and in some cases the training to enable them to be competent in managing these behaviours. Alongside this there have been many staff changes and this could lead to a lack of continuity in delivering this persons care. This discussed with the manager who said that some staff still required this training. There are protocols (written guidelines to support staff), in place for the specialist needs of the individuals living in the Home. One of these relates to life threatening Epilepsy. None of the staff on duty had undertaken the training needed to allow them to administer medication to support the person in the event of a serious seizure. Staff did however demonstrate what to do an emergency, and this was in line with the protocol in place. The manager said that he is waiting for a date for staff to do Epilepsy training and for the written protocol to be implemented. From discussion with staff and the acting manager the following training information was gathered, but not verified. There is some staff that requires training in first aid, epilepsy, safe management of medicines and MAPA. A good Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 29 programme of training had been put into place during 2006 but in the absence of the AQAA information and no access to training records there is a need to develop 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 it is not possible to establish the percentage of care staff that have received training to NVQ2 or above. A judgement could not be made as to the recruitment checks being carried out. Previous information about this service indicates that appropriate references and police checks and checks with the protection of vulnerable adults register, (POVA), are carried out prior to employment. All documents required under Schedule 2 of the Regulations must be obtained prior to employment and these must be available for inspection. Many changes to the staffing group have taken place the manager needs to complete a staff training needs audit to ensure that staff have the required training, skills and knowledge to meet people needs. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 30 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, &42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The Home has not demonstrated that it is managed in a way that promotes good outcomes for people using the service. Some progress is evident in developing the care practice however progress has been compromised due to the high turnover of senior staff to support the manager in this role. EVIDENCE: Over the last few months there have been several changes to the staffing and management compliment at Beech House. The provider had informed CSCI of the temporary management arrangements, which included an acting manager who has worked in the Home since April. The acting manager was not on duty on the day of the visit to Beech House. He has a number of year’s experience of working with people who have a Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 31 learning disability. He has experience of working with people who suffer the effects of sensory loss, degenerative disease, autism, mental ill health and other complex needs. The acting manager has completed NVQ level 4 and the registered managers award, although this was not verified at the time of the visit. He has the required management skills and knowledge to ensure the Home is run effectively. Rotas show he is working many ‘cross shifts’ to fill the gaps in the rota, and support the staff team who are on shift. He has no management support on site, and this is a difficult time for the service. There are three senior posts and a deputy post vacant, this has meant that existing staff at the home are covering the three senior posts, these staff are working as ‘shift leaders’. The shift leaders are not experienced to share some of the roles, responsibilities and tasks, and as such the acting manager has an increased workload. This was discussed with him and he said that the Organisation had offered support from a manager who works within the organisation, but this was declined. The manager must seek support, as much work is needed in this area. The interim management arrangements need to be reviewed as a priority. There are shortfalls, raised throughout this report, which are of concern and must be addressed so that people are not put at risk. Many of the systems that are in place are not effective and as a result people are experiencing variable outcomes. The manager has acknowledged that there is areas where they need to make improvements and needs to develop an action plan for undertaking this work. From discussion with the manager and some of the new documentation seen in the Home, it is evident that the manager is developing systems to improve the care practice. He is keen to develop person centred planning to achieve better outcomes for the people who use this service. However there is difficulty in translating this into practice, due to the high turnover of senior staff to support him in this role. It was positive to see that the provider has carried out monitoring visits of the Home. These visits are designed to ensure discussions take place with people living in the home and a tour of the premises is made to form an opinion about how the Home is being run. The reports looked at should provide for comments received from the people who live at the Home, the format of the monitoring form does not provide for a detailed description of the findings, more of a tick and score chart. Given that this home has failed to provide good outcomes for people it is important that the owner has good oversight of the areas for development so they can influence change. Quality assurance systems have not been assessed on this visit, this information was not available. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 32 The manager failed to complete an AQAA (annual quality assurance assessment), which tells CSCI about how well the Home is performing and achieving outcomes for the people who live in the Home. This remains an outstanding requirement. The management of health and safety required some improvement. Safety checks were looked at including hot water temperature checks, gas safety testing, fire safety checks and work place fire risk assessments. These are important to protect the safety and well being of people living at the Home. The gas safety certificate seen was dated May 06 this is out of date, the acting manager must ensure that there is a current in date gas safety certificate. The recording of the last fire drill was February 2007 the acting manager must ensure that drills take place regularly and at least every six months to ensure that all staff working in the Home know how to safely support people in the event of the alarm being activated. The weekly fire alarm test recordings were regularly done on a weekly basis, but the last entry was 30th August and this was out of date by a few weeks. Some of these records were being transferred to new recording formats, it may well be that these safety checks have been carried out but that the record was somewhere else. It is important that there is a well-maintained and up to date record available for inspection to show safety checks are being complied with. The management of accident and incidents was found to be satisfactory, concerns are logged on the required forms and notified to the Commission. Follow up action had been recorded. The management of medication was a concern as stated under standard 20. No member of staff on duty had a current first aid qualification and this is concerning as the people who live at Beech House are vulnerable to falls and injury. The inspector was informed that the vacant posts have been advertised. The service will need to submit an application for the registered manager post. Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 33 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 2 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 2 14 2 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X X X X 2 X Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 34 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA2 Regulation 14(1)(a) Timescale for action A comprehensive assessment of 26/11/07 needs must be carried out before the person moves in to the Home. This will ensure that the Home can meet the persons’ needs in respect of their health and welfare. A comprehensive support plan 26/12/07 must be in place for each person detailing how the staff team will meet his or her assessed needs. This must be kept under review so that it provides clear guidance on the person’s current needs. Behaviour guidelines must be 26/11/07 included in the care plan so that staff knows how to support the person safely, and the steps to be taken to minimise self-harm. The risk assessment in place 16/11/07 for the use of protective helmets must be reviewed and the practice clarified to all staff so that people living in the Home are protected from injury. The risk assessment for staff 16/11/07 support at mealtimes must be DS0000028592.V348082.R01.S.doc Version 5.2 Page 35 Requirement 2. YA6 15 (1) (2) 3 YA7 15(1) (2) 4 YA9 13(4)(c) 5 YA17 13 (4) (c) Beeches (The) (Seven Kings) 6 YA19 7 YA20 8 YA23 9. YA24 10 YA33 11 YA35 reviewed so that individuals support needs are clear during mealtimes, to protect people from choking or self-harm. 12 (1)(a)(b) There must be a Health Action plan in place for each person, so that anyone looking at it can see clearly what needs to be in place to keep the person safe and healthy. 13(2) When medication is administered to people who use the service it must be administered by staff who have received accredited training in the safe handling of medicines, to ensure that people receive their medication in a safe manner. A proposed training plan must be submitted to the Commission identifying training dates. 13 (6) Arrangements must be made to ensure that all staff has an understanding of adult protection and whistle blowing procedures. This is to ensure that people are not put at risk. A proposed training plan must be submitted to the Commission identifying training dates. 13(4)(a) Dining room chairs must be assessed for the risk they present to the people that use them, and action taken to minimise any identified risk. 18(1)(a) Staffing levels must be reviewed to ensure there are adequate numbers of staff at all times and particularly at peak periods, to meet peoples assessed needs. 13(6) Safe restraint techniques (MAPPA training) must be provided for all staff that work with people that have been assessed as having self DS0000028592.V348082.R01.S.doc 26/12/07 26/11/07 26/11/07 16/11/07 26/12/07 26/11/07 Beeches (The) (Seven Kings) Version 5.2 Page 36 12 YA35 18(1) (c) (i) 13 YA35 12(1)(a) 14. YA37 8(1) (a) 15 YA37 24 (a) (b) 16. YA42 13(4) harming behaviours. This will ensure that staff knows what to do to protect the person from harm. A proposed training plan must be submitted to the Commission identifying training done and needed. Intervention training must be provided for all staff that work with people that have been assessed as having behaviour that challenges, this is to ensure they know what steps to take to minimise such behaviour. A proposed training plan must be submitted to the Commission identifying training done and needed. Staff must receive training in the management of Epilepsy in line with the new protocol in place. This will promote the health and welfare of the individual. A proposed training plan must be submitted to the Commission identifying training done and needed. A Registered Manager must be approved to ensure the Home is run effectively. The service must advise the Commission of their proposal and timescale on this matter. The manager must complete an AQAA (annual quality assurance assessment), which tells CSCI about how well the Home is performing and achieving outcomes for the people who live in the Home. This requirement was made on 3rd September 2007, and remains outstanding. The service has been informed that enforcement action may be taken against them. There must be at least one first aid trained person in the home DS0000028592.V348082.R01.S.doc 26/11/07 26/11/07 26/11/07 22/09/07 26/11/07 Beeches (The) (Seven Kings) Version 5.2 Page 37 17 YA42 23(4)(e) 18 YA42 23(4)(ii) at all times, to make sure that people who use services receive appropriate treatment in an accident. A proposed training plan must be submitted to the Commission identifying training done and needed. Fire drills must be carried out 09/11/07 every six months. This will ensure staff knows how to keep the people living in the home safe. Fire alarm tests must be carried 09/11/07 out and recorded to ensure adequate precautions against the risk of fire are carried out. 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. Refer to Standard YA1 YA22 Good Practice Recommendations Information about the Home should be available in a format suited to blind and visually impaired people so that they have better access to information that concerns their stay at the Home. Person centred plans should be implemented in a format suitable to the needs of people who are blind or partially sighted so that it is meaningful and personal to them. There should be evidence that people have been supported to make decisions, and staff can demonstrate how choices have been made, for instance in relation to managing finances, self help and independent living skill, personal goals and aspirations. Daily records should be developed so that peoples needs and choices can be properly monitored. It must be clear how people are consulted about the range of activities and leisure pursuits provided within the Home and the local community particularly for those who are dependent on staff support. DS0000028592.V348082.R01.S.doc Version 5.2 Page 38 2. YA6 3 YA7 4. 5 YA7 YA13 Beeches (The) (Seven Kings) 6 7 YA14 YA18 8 9 10 YA24 YA32 YA34 The choice of hobbies and interests needs to be clear with a means of measuring outcomes for people in this area. There should be a profile to show that staff have completed training in the management of incontinence and up have up to date manual handling training to demonstrate people are supported by a competent and qualified staff team. Consideration of brighter colours and décor in keeping with younger adults would enhance the environment. There should be a profile to show that 50 of care staff has completed NVQ level 2 to demonstrate people are supported by a competent and qualified staff team. Recruitment information must be available for inspection, to demonstrate that appropriate checks have been made to ensure staff working with the people in the Home, are safe to do so. There should be a profile to show staff can meet the specific requirements relating to the new Epilepsy protocol, this will ensure staff can meet peoples needs. A copy of the up to date gas safety certificate must be available in the Home as evidence that safety checks have been completed. 11 12 YA35 YA42 Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection 3rd Floor 77 Paradise Circus Queensway Birmingham B1 2DT 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 Beeches (The) (Seven Kings) DS0000028592.V348082.R01.S.doc Version 5.2 Page 40 - 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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