CARE HOME ADULTS 18-65
Beech Lodge - Deafinitely Independent 28 Warwick New Road Leamington Spa Warwickshire CV32 5JJ Lead Inspector
Kevin Ward Announced 23 August 2005 09:00 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 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 Stationary 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 Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION
Name of service Beech Lodge - Deafinitely Independent Address 28 Warwick New Road Leamington Spa Warwickshire CV32 5JJ 01926 337743 01926 337743 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Deafinitely Independent Mr Karl M Davis Care Home 8 Category(ies) of Learning disability - (8) registration, with number Physical disability - (8) of places Sensory Impairment (8) Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: 1. All service users must have a learning disability and a hearing disability. 2. That Karl Davis successfully completes the NVQ Registered Managers Award by 1 April 2006. 3. That Karl Davis successfully completes the NVQ in Care at level 4 (or whatever title that the GSCC may give to this award in its review of 2005) by 1 April 2006. 4. That Karl Davis notifies the Commission for Social Care Inspection when he has achieved these qualifications. Date of last inspection 10 January 2005 Brief Description of the Service: Beech Lodge is a “parent led” voluntary organisation that provides 24-hour personal care for eight adults who are deaf and also have a learning disability. It is a large detached property, formerly a hotel. It is on a busy main road, near to a college of further education, shops and parks. It has gardens to the front and a tarmac drive leading to a large space for cars and a small courtyard garden at the rear and an enclosed garden to the side. On ground floor level there is a hall, a spacious lounge, a large dining room, an equally large communal kitchen/dining room and two staff offices. Leading to the rear of the building there is a short flight of steps into the back corridor. Here there are two bedrooms with en-suite facilities, suitable for people with physical disabilities. The staff sleeping-in room is situated in the same area. A large, new laundry has been created. The corridor ends in a back door straight out onto the tarmac parking area. There is a double garage and a walled courtyard garden with barbecue. There are large, dry cellars at the bottom of a flight of stairs.On the first floor there are two bedrooms with en-suite facilities for residents and another staff office. There is a flight of stairs leading to the top floor. There is a small seating area on the landing and a door leads through to a lobby with four more bedrooms off this, with en-suite bathrooms. There is a small, shared kitchen off the lobby that is suitable for making snacks and drinks. Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This announced inspection involved talking with 5 of the 6 service users who live at the home and were present on the day, so that they could share their views about the home. The inspection also involved meeting with the manager and separately with staff, to discuss policies and practices in the home. A sample of service users’ care plans and records were examined and a number of policies and procedures were looked at to confirm their availability in the home. A sample of staff recruitment files were also examined to assess the home’s recruitment procedures. A British Sign Language interpreter assisted the inspector to communicate with Deaf service users and staff during the afternoon of the inspection. What the service does well:
Care plans and other information is in place to enable staff to provide people with the care and support they are assessed as needing. Good work has been carried out to make this information more easily accessible to service users, e.g. using photographs and illustrations. People are supported to take part in their reviews and receive support beforehand to prepare for these meetings. This includes the use of videos, recording their views. The home also provides good accessible information to service users, including information about the home and a good accessible complaints policy that contains photographs advising people who they may complain to. Comments made by staff demonstrate a good awareness of the needs of people living at the home. “Signed” comments made by service users indicate that they feel happy and well supported by staff at the home. Staff were seen to relate warmly to the people living at the home and service users appeared very comfortable and ease in the company of staff. During the week people are supported to attend college courses for part of the time and are provided with daytime support from staff at the home at other times. Examples of college courses attended, included cooking, gardening, farming with small animals. People also confirmed that they are supported to enjoy a good range of social activities, including some specialist clubs, and other community based activities, such as shopping, pubs, clubs and theatre. Service users have also been supported to enjoy a good range of outings, such as Cotswolds, zoo, Cinderella on ice and other day trips. Risk assessments and guidelines are in place at the home addressing people’s individual needs, such as epilepsy, as well as general hazards in the home should as risks of trips and slips. Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 6 Service users are being supported to make use of appropriate specialist health services, such as psychiatrists and psychologists as well as being assisted to make use of everyday health services, such as GP, chiropody and dentist. Staff at the home are provided with access to a very good range of training courses in care practices and health and safety related subjects, such as first aid and food hygiene training. Staff are being supported to undertake NVQ training courses and 5 staff (including the manager) have been trained to level 4 in care, which is a high level of training normally reserved for managers. The manager is in the process of completing the Registered Managers Award so that he is fully qualified to manage the home in accordance with current requirements. The home has a good quality assurance system in place which includes devising action plans to address any issues that are identified as part of this process. Copies of questionnaires, completed by visiting professionals, were seen on file. An examination of these forms identified many positive comments about the home. What has improved since the last inspection? What they could do better:
As noted above people’s needs are being reviewed on a regular basis at meetings involving their social workers, relatives and staff of the home.
Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 7 However some individual plans are not being routinely updated after these meetings, to confirm that they have been reviewed and amended to reflect any changes identified at review meetings. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These Standards were not assessed on this occasion. EVIDENCE: Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 and 9 The people living at the home are provided with accessible information and encouraged to attend review meetings so that they can contribute to plans for their care and support. Individual plans need to be routinely dated following reviews to confirm that any necessary amendments are recorded. Positive work is carried out to provide people with accessible information so that they are better able to communicate their decisions, make choices and make their feelings known. Risk assessments are in place so that staff are able to support people to maintain their independence in a safe manner. EVIDENCE: A sample examination of people’s care plans confirmed that very positive work has taken place to personalise these documents with photographs and illustrations to make them as accessible as possible for people. In addition to “individual plans” good work has been carried out to devise written information summarising people’s personal routines throughout the day and written “snapshots” provide helpful background information about people’s needs. Care plan reviews are taking place, which include the involvement of service users, relatives, social workers and keyworkers. Comments made by service
Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 11 users confirmed that they receive support from their keyworkers to prepare for their reviews and to understand decisions that are made at these meetings. This includes the use of video taped consultations to help people to express their views at review meetings. Records are being kept to confirm that staff have regular one to one meetings with service uses to assist them to make day to day plans and address their needs. Conversations with service users confirmed that they have been issued with copies of their personal plans, which they keep in their bedrooms with other information about the home. Some care plans have not been recently dated, following service user reviews. This is necessary to confirm that the information in the plans is still fully up to date and that amendments arising from review decisions are being made to the plans. Service users are issued with a copy of their personal care plans for safekeeping in their bedrooms. The home supports people to make choices and decisions in a number of ways. Monthly meetings are held with the service users of Beech Lodge and Chestnut Lodge that are facilitated by an advocate. A written record of these meetings is retained in Chestnut Lodge. The meetings are also video taped so that service users who miss the meetings are able to catch up on events, if they wish to do so. Comments made by service users and staff confirmed that people receive regular one to one support sessions with their keyworkers, to monitor their immediate needs and make plans to meet them, e.g. plans to shop for clothes or prepare for reviews. A choice menu is in place with three options for people to choose from at each main mealtime. Staff were seen to record service users choices during the course of the inspection. A new photographic menu is being developed to help people to make choices about the meals they would prefer. This contains colourful photographs of meals provided at the home for people to choose from. The manager explained that the home has purchased new “board maker” equipment to be used to aid communication with a number of people at the home. The home makes positive use of photographs, videos and other means to support communication with service users to help them make decisions that affect them. All staff are provided with BSL training and this training is also being given to a number of service users to help to them to improve their communication skills. Some service users have developed their own personal signs to communicate their needs. Examples of people’s individual signs can be found in their personal snapshot information, in their care plan files, to inform new staff. A range of environmental risk assessments are in place at the home addressing everyday hazards, such as the slips and trips, use of the home’s vehicle and storing hazardous substances, e.g. cleaning materials. Risk assessments are also in place to address hazards that are associated with individuals needs, e.g. health needs. A new revised epilepsy protocol has been devised and signed by health professionals, to support people in administering new medication for one person who experiences severe seizures on occasions. Discussions with staff demonstrated a good awareness of the protocol and of other guidelines that are in place for supporting this person.
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The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16 and 17 The home supports people to gain access to a suitable range of educational, employment and community based leisure activities so that they have opportunities for personal development and to take part in the life of the wider community. People are able to receive visits from relatives and friends so that they can maintain relationships with people who are important to them. The home supports people to maintain their privacy and confidentiality so that their rights are recognised and respected. People are consulted about the food provided so that they receive balanced meals that they enjoy. EVIDENCE: During the week service users either attend college courses or are supported to undertake activities with staff support. Examples of courses, included pottery, gardening, woodwork, cooking and farming animals. It was the college holiday period at then time of this inspection and staff were seen to support
Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 13 some service users with art activities for part of the time. Outings and day trips are also arranged by the home. A trip to Weston Super Mare was planned for the day following this inspection. Staff and service users confirmed that many other outings have been provided recently, e.g. zoo trip, dog show, Cotswolds, Russian ice-skating and Cinderella on ice. Service users are also supported to attend the Gateway and PHAB club on a regular basis and enjoy trips to pubs and clubs as well as in house activities, such as art group, video evenings and one to one cooking sessions. Service users confirmed that they are supported to go on holiday with the home. Entries in service users records confirm that service users are supported to maintain contact and receive visits from their relations. Service users’ review notes demonstrate that people are commonly provided with support and representation from close relatives at their review meetings. The manager explained that service users are able to invite their relatives or friends to visit them for a buffet tea on their Birthdays although some people prefer to go out for meal. The manager stated that the majority of service users visit their relatives over the Christmas period and that relatives are encouraged to visit the home throughout the year. Service users are issued with keys to their bedroom doors for them to use where they wish to do so. Service users personal mail is passed to them to open themselves and so respect their privacy. A record is retained to log the letters passed to people as evidence of this fact. Service users have been issued with a copy of the confidentiality policy and are able to see their personal records, with support from staff, whenever they wish to do so. As previously noted service users are issued with copies of their personal plans to keep in their bedrooms. Service users confirmed that they are very happy with the food provided at the home. As previously noted three main mealtime options are provided on the choice menu. Service users confirmed that they are consulted about the contents of the menus, which are based on their preferences. Snacks are available in the home and staff explained that encouragement is given to eat healthy options, such as yoghurt and fruit. Two service users share a kitchenette attached to their bedrooms where they are able to make themselves snacks. A record of all fridge and freezer temperatures is maintained as evidence that these appliances are being monitored to ensure that they work effectively. Fresh fruit was observed to be available for people in the kitchen area to help themselves. Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 and 20 Consideration is given to people’s needs and personal routines so that they receive care and support in the way they prefer and require. The home supports people to gain access to appropriate health professionals so that their healthcare needs are identified and addressed. Service users are supported to take responsibility for their medication, where it is considered safe to do so and procedures are in place so that staff follow safe medication practices. EVIDENCE: Signed comments by service uses indicate that that they feel well supported by staff at the home. All service users have en suite facilities for their personal use. A number of bathroom areas have been equipped to meet the specific needs of the people using them, e.g. walk in showers, grab rails and shower seats. All service users are ambulant and the manager confirmed that no one requires the assistance of hoists or other lifting equipment. A staff member was observed to knock and wait for a response before entering people’s rooms, demonstrating a suitable regard for people’s privacy. Service users daily routines are recorded in the care plan files for staff to follow. Service users were seen to move freely about the home in a relaxed manner and to look very at ease in their home environment.
Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 15 Since the last inspection staff have received training by a qualified nurse to equip them for checking people’s blood pressure. New epilepsy protocols have also been devised for one service user and have been signed by the health professionals involved. Comments made by staff confirmed a good awareness of the protocols and guidelines in place and of the needs of the service user concerned. Behaviour management guidelines are also in place for two people that have been written with the involvement of a psychologist, to assist staff respond appropriately and consistently to presenting behaviours. Satisfactory records are in place, detailing the outcomes of people’s health appointments. These records indicate that service users are being provided with appropriate access to specialist health professionals, such as consultant psychiatrist, epilepsy nurse, psychologist, as well as general community health services, e.g. GP, dentist, well person checks and chiropody. A lockable storage cabinet is in place for the safekeeping of service users’ medication and satisfactory arrangements are in place for signing and accounting for tablets and medicines that are given to people. In addition to signing at the time medication is given staff a staff member is also required to carry out a second check of the medication records at the end of the day to ensure that all medication has been given and signed for appropriately. Since the last inspection the medication policy and procedure has been amended to include the monitoring arrangements that are put in place for people who administer their own medication. Three monthly audits of the medication systems are being carried out by the pharmacist to monitor and support good practice in the home. Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 People are provided with information and opportunities to complain so that their concerns may be listened to and acted upon. Staff are provided with appropriate procedures and training so that they are able to recognise and respond to any suspicions of abuse, so that people are properly protected. EVIDENCE: A complaints policy is in place at the home and an accessible version, containing photographs of people to whom service users may complain, has been issued to everyone living at the home. People are provided with opportunities to raise any concerns / complaints at monthly meetings and at one to one sessions with their keyworkers. Service users confirmed that they are very happy at the home and no complaints were elicited during the course of the inspection. The manager confirmed that there have been no complaints at the home since the last inspection. The manager agreed to devise a paperwork format for recording and tracking any complaints that are made to the home in the future. Adult abuse procedures are in place at the home and a whistleblowing procedure is available, advising staff how to raise any concerns they might hold about the ruining of the home. Comments made by staff indicated a satisfactory awareness of the procedures for reporting any suspicions of abuse or any concerns they might hold about the running of the home. Training has been provided to staff to underpin their understanding in this important area of practice. Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 17 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 Suitable arrangements are in place for the repair and maintenance of the home so that people live in a homely, comfortable environment. EVIDENCE: Beech Lodge is a very large Georgian house that is within reasonable walking distance of the local town. Overall the home is decorated and furnished to a satisfactory standard. Whilst further work is necessary to redecorate some rooms this is being appropriately addressed as part of the home’s maintenance and renewal programme. Downstairs the building is accessible to people with disabilities and the home is equipped to meet the needs of all the people that currently live there, who are all ambulant and able to climb the stairs. The home is comfortable and homely and is equipped with domestic style furniture. People’s bedrooms are of a good size. Positive work has recently taken place to refurbish and equip the main kitchen. Similarly work has taken place to refurbish kitchenette facilities that are shared by two people and to fit a washing machine for their use. A patio door has also been fitted in one person’s room and the Director explained that work is ongoing to upgrade the sash windows in the home.
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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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 and 35 Satisfactory systems are in place for interviewing and vetting new staff so that service users are safeguarded by the home’s recruitment procedures. The home provides a comprehensive range of training opportunities so that people receive support from a competent and well trained staff team. EVIDENCE: Staff at the home also work next door, at another of the organisations homes, Chestnut Lodge, on occasions. Recent staff recruitment files were examined at an inspection of Chestnut Lodge, which took place two week prior to the inspection of Beech Lodge. Overall the home’s recruitment practices were found to be satisfactory at that time, with the exception that there was a need to update some information for a member of staff who had moved from a voluntary position to a paid position. This requirement has since been met. The Director explained that the organisation makes use of just one agency worker, where necessary. An examination of this persons file confirmed that the home now holds evidence to confirm that all the necessary checks and references for safeguarding vulnerable adults have been taken up by the agency. Criminal Record Bureau checks have been taken up appropriately for all new employees to confirm that they have no offences that would bar them working at the home. Service users are being encouraged to take part in staff interviews and a record of their comments is retained on staff files as evidence of their involvement in the interview process.
Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 19 Information provided by the manager and comments made by staff confirmed that the home provides an excellent range of training opportunities for staff. In addition to health and safety related courses such as fire safety, first aid, and food hygiene training, staff also attend training designed to develop good care practices, such as NVQ training courses. In addition to the manager 4 staff have been supported to complete NVQ level 4 in care, which is a higher level of training than is generally provided to care support workers. The manager explained that two more staff are planned to start NVQ level 4 training shortly. Staff are trained in the use of British Sign Language at various levels and a number of staff have been provided with Deaf-blind communication/awareness training. Other examples of practice courses, include, epilepsy, counselling and person centred planning. Learning Disability Award Framework, induction training has been provided and NVQ training courses are strongly supported by the organisation. The manager holds the NVQ level 4 in care qualification and is in the process of completing the Registered Managers Award. Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 20 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The home has procedures in place for monitoring quality assurance and for seeking the views of service users, relatives and professionals so that people’s interests are safeguarded. Appropriate arrangements are in place for maintaining equipment in the home so that the health and welfare of service users is protected. EVIDENCE: Evidence is in place to demonstrate that the home has systems for monitoring quality assurance in the home. The “PQASSO” quality assurance system is in operation in the organisation. Action plans are being developed to bring about improvements, where necessary. The action plans reflect a joint approach from managers and staff, at the various levels within the organisation, to support a shared commitment to any work that is required. As previously noted service users meetings take place at the home, providing opportunities for people to express their views about the service. These meetings are chaired by someone who is not directly employed in the home, to provide an element of independence. Positive action is being taken on an ongoing basis to seek the
Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 21 views of relatives and professionals by means of quality assurance questionnaires. Regular visits are being carried out at the home on behalf the Responsible Individual, resulting in informative reports to assist the manager to monitor practices in the home. A copy of the organisations end of year accounts provides evidence to confirm that the organisation has satisfactory financial planning arrangements in place for the development of the home. The organisation is setting aside funds to continue environmental improvements at the home, whilst maintaining financial, security within the organisation. Information provided by the manager prior to the inspection indicates that appropriate measures are taken for maintaining health and safety in the home. An examination of the fire safety log confirms that alarms and emergency lights are being tested at an appropriate frequency and that fire drills, are being carried out at the home. Flashing lights are also in place to advise people when the fire alarm is sounded and service users are provided with vibrating alarms under their mattresses’ so that they are made aware, should there be a fire at night-time. Maintenance certificates confirm that gas and electrical equipment is being routinely checked as required. A test of the home’s hard wiring has been carried out, in keeping with a requirement of the last inspection. A range of environmental risk assessments are in place at the home addressing everyday hazards, such as the slips and trips, use of the home’s vehicle and storing hazardous substances, e.g. cleaning materials. Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 22 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 4 x 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 4 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Beech Lodge - Deafinitely Independent Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 23 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. 2. Standard 6 Regulation Requirement Ensure that individual plans are amended and dated following review meetings. Timescale for action 30/9/05 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 Good Practice Recommendations Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Imperial Court Holly Walk Leamington Spa CV32 4YB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beech Lodge - Deafinitely Independent E53 S4233 Beech Lodge Deafinitely Independent V240106 230805 Stage 4.doc Version 1.40 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
