Inspection on 17/02/06 for Beech Tree Hall

This inspection was carried out on 17th February 2006.

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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beech Tree Hall 11/01/07

Beech Tree Hall 09/09/05

Beech Tree Hall 15/12/04

Beech Tree Hall 16/06/04

Beech Tree Hall 03/02/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Beech Tree Hall Marsh Lane Arksey Doncaster DN5 OSQ Lead Inspector Janet McBride Unannounced Inspection 17th February 2006 11:15 Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech Tree Hall Address Marsh Lane Arksey Doncaster DN5 OSQ 01302 875001 01302 875001 beechtreehall@tiscali.co.uk 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) Mr Donald Smith Michael Robert Wilson Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The accommodation to include four separate units for four service users in each unit. Up to 8 beds can be used for young people aged 16 and 17 Date of last inspection 9th September 2005 Brief Description of the Service: Beech Tree Hall provides up to 16 places for young adults with Autistic Spectrum Disorders, the home has been registered since it opened in May 2001.The home is located in the village of Arksey on the outskirts of Doncaster. Accommodation is provided in one of four units, at the home, which are Oak House, Holly House, Birch House, and Elm House. The first three are located on the ground floor, each with its own front door and access to the gardens at the rear of the home. Elm House is located on the first floor and caters specifically for adults affected by Asperser’s Syndrome. One-to- one staffing is usually essential to allow each individual service users plan to be followed to the full. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Inspector from the Commission for Social Care Inspection carried out this unannounced inspection at Beech Tree Hall, on the 17th February 2006, commencing at 11:15 and finished at 16:15. This was the home second Inspection since April 2005,any standards not covered in this inspection was covered in the unannounced inspection that was conducted early in the year. It may be the case that some standards will be covered twice in the inspection year 2005/2006, which is considered good practice, and consistent with a professional approach to regulation. During the Inspection we looked at chosen number of documents, sampling of records, tour of the premises and direct and indirect observation of staff interaction with residents Any issues or concerns that were raised were discussed with the manager during and at the end of the Inspection What the service does well: What has improved since the last inspection? The home has addressed all requirements that were made on the last inspection. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Prospective service users individual needs are assessed prior to admission to ensure that the home will meet their needs. EVIDENCE: All referrals for admission have the required documentation giving the history of the potential service user, they are then assessed by the homes manager, the homes programme coordinator plus a support worker will also carry out a pre-placement visit to the potential service user. A pre-placement visit involves direct observation of the potential service user, meetings with their current carers, educationalists and family as part of the assessment process. Appropriate communication techniques including the use of symbols, pictures and photographs are employed as part of the process. Observation documents on service users files were read and discussed this process with key worker and coordinator. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 679 The home as worked hard at improving the care plans, they reflect what care is needed and are reviewed and updated, this ensures that staff have the information to meet service users care needs. EVIDENCE: The home has an appointed programme co-ordinator who gives advice and supports staff in developing individual care plans. Service users care plan is devised from the assessment; two care plans were examined and discussed with the key workers. Care plans reflected the needs of that individual, with appropriate risk assessments in place including risk assessments for any daily activities or social activities that they participate in, and records show they are reviewed and updated on a regular basis. Evidence was seen that when staffs are developing care plans for each individual service user consideration is given to the impairments brought about by their autistic condition, e.g. the absence or impairment of social interaction, and impairment of communication. All care plans addresses these impairments and provides strategies aimed at reducing them, enabling each service users having the opportunities to learn and use practical life skills and increase their confidence. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 10 Appropriate psychiatric input and continued support, is evident as the home as the services of a psychiatrist specialising in Autistic Spectrum Disorders who reviews service users on a regular basis and there for support if needed for the staff. Each service user is assessed on their ability to make decisions about all their daily living needs, and are involved with their key worker and have plans in place to do daily tasks on what ever level they are able to participate in, and evidence was seen that the home uses appropriate formats to give information to the service users. Advocacy groups are available to support service users as the home used them in the past when needed. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 16 17 The daily routines and lifestyle for service users are being met by the home, they provide day care opportunities, regular communal and leisure activities, which promote an enjoyable life for the service users. EVIDENCE: Links are maintained with family and friends with the support of staff, for example staff assists service users to keep in contact either by letters or by telephone. Most service users have regular home visits; especially holiday times. Service users do have the opportunity to participate and mix, dependent on the individual’s ability, for example some of the activities are enjoyed as a group and other activities are carried out with each individual as part of their service user plan. Staff was spoken to on the day of Inspections and asked about daily routines within the home; from their responses it was evident that staff respects service users rights and tries to promote independence, choice and freedom. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 12 Each service user plan clearly shows the individual’s ability to carry out tasks and make choices independently. Limits are only imposed where risks are identified, e.g. having no awareness of the dangers that sharp objects bring, unawareness of hot and cold-water differences or destructive behaviour in certain settings. Accommodation of the four units is such that service users cannot wander freely from one unit to the other and invade the privacy of others. Although the home promotes a healthy and nutritious diet, some service users at times choose not to adopt this, but evidence was seen that staff encourage them with healthy options, and those service users who are capable help prepare food and make their own packed lunches. Service users are weighed on a regular basis and staff assess when they need to make a referral to a dietician if any concerns or issues are identified. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home polices and procedures for safe handling of medicines ensure that the storage, administration and recording protect service users from harm. EVIDENCE: There are policy and procedures in place for the safe handling of medication, records were checked and found satisfactory with the exception of some Mar sheets that are hand written by staff must be signed by two staff to verify prescribed medicine. Discussion with staff how they administer medicine when residents attend day care or go on home leave, no residents have medicine at lunch time at the present, and when they go on home leave they take the original pack, and staff record what medicine is taken. No service user administers their own medication as risk assessments conclude that this would be unsafe. Support workers who are also allocated as keyworkers to individual service users have completed an accredited medication course and are familiar with that individuals preferred way of taking medication. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were assessed at the last inspection and met. EVIDENCE: Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 28 Service users live in a well maintained home that is homely, comfortable and safe environment that meets their needs. EVIDENCE: Maintenance of the home is carried out by the homes handy man, which ensures that any general maintenance of the home is carried out when required. The home continue to replace windows that have wood rot, it’s been a slow process, as they all have to be individual made but most have now been replaced. Tour of the home found it to be a clean, tidy and comfortable environment for service users. Because of the client group at the home furniture and fittings within the home area replaced on a regular basis, and ongoing refurbishment is required and the kitchen on oak unit was identified as very worn and requires refurbishing. Each unit as a range of safe and accessible shared space, accommodation of the four units is such that service users cannot wander freely from one unit to the other and invade the space and privacy of others. Shared space includes outside areas, and service users have unrestricted access to outside areas. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31 32 33 34 35 36 Stable staff group within the home, who work effectively as a team. Staff is competent and qualified to support service users and work positively with them to improve their quality of life. EVIDENCE: It was evident when staff member were interviewed were aware of their roles and responsibilities within the home, could give a clear account of the care given to service users, also aware of the protection of vulnerable people and knew about whistle blowing. NVQ training can be accessed through the home, and three members of staff have achieved their NVQ and six other members of staff are in progress of achieving NVQ level 2 or 3. To support staff on relevant courses the home has two NVQ assessors within the home. Duty rota for staffing was discussed with the manager, who stated that ratios of staff hours are determined according to the assessed needs of the service user, 1:1 staffing ratios employed at the home during the day, as all service users are allocated 1:1 staffing as part of their service user plan, however evidence seen that extra staff are used when needed as the manager reviews staffing numbers on a regular basis. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 17 The home operates a thorough recruitment procedure based on equal opportunities; four staff files were examined and found that all the recruitment policy and procedures had been followed, but one issue was raised, files must contain proof of the persons identity, including a recent photograph. The manager ensures that there is staff training and development programme for staff at the home, this was evidenced by a training matrix which shows all staff are either on a skills for care course or NVQ course (copy on file) this was also confirmed by staff seen on the day, who also stated they are encouraged in training and development. Management at the home provides supervision and appraisal to the care staff team, this includes informal daily supervision through visits to the four units, and formal supervision with records kept. Staff interviewed on the day confirmed they receive supervision on a regular basis, and state that care issues and training and development are discussed within supervision sessions, and team meetings are held monthly with recorded minutes taken. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 41 42 The homes manager provides leadership and management, which promote service users well-being; health and safety arrangements are in place to ensure that service users health, safety and welfare are protected. EVIDENCE: The manager as considerable work experience with adults affected by ASD, and has completed The Registered Managers Award. Those staff spoken too confirmed that the manager his very supportive and encourages training and development for staff. Records seen were up to date and accurate, with the exception of Regulation 37 incident forms not being completed and sent to the Commission for Social Care Inspection. Service users records were found to be kept secure and in locked cabinets, in accordance with the Data Protection Act. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 19 Health and safety was assessed at the last inspection and met, therefore only partly assessed at this inspection. Discussion with the manager and staff how they ensure health and safety of service users, they stated appropriate policy and procedures are in place which are promoted to ensure service users are safe and protected from harm. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 3 29 X 30 X STAFFING Standard No Score 31 3 32 2 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 3 X X X 2 3 X Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 21 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 YA20 Regulation 13(2) Requirement Medication, MAR sheets that are hand written must have two signatures to verify prescribed medicine. Kitchen on Oak unit requires refurbishing. Staff personal files must include proof of the person’s identity, including a recent photograph. Notification; must be sent to the Commission without delay of the occurrence of; see reference in Regulation 37 Timescale for action 20/02/06 2. 3. 4. YA24 YA34 YA41 23(2)(b) 19 Schedule2 17(2) Schedule4 30/04/06 31/03/06 20/02/06 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 YA32 Good Practice Recommendations Continue with the training strategy planned to achieve a minimum ratio of 80 trained members of staff acquire the appropriate level 2 NVQ qualifications. Beech Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Tree Hall DS0000008012.V284003.R01.S.doc Version 5.1 Page 23 - 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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