Inspection on 09/09/05 for Beech Tree Hall

This inspection was carried out on 9th September 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 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 17/02/06

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 09 September 2005 10:40. 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 Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 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 Mr Donald smith 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) Michael Wilson Care home only 16 Category(ies) of Learning disability (16) registration, with number of places Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: . The accommodation to include four separate units for four service users in each unit. 2. Up to 8 beds can be used for young people aged 16 and 17 Date of last inspection 15-Dec-2004 Brief Description of the Service: Beech Tree Hall provides up to 16 places for young adults with Autistic Spectrum Disorders, the home is registered with the National Care Standards Commission and has been open since May 2001. 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 Asperger’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 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by one Inspector and commenced at 10.40 and finished at 15.30 The inspector assessed a proportion of the National Minimum Standards; those key standards not assessed at this inspection will be assessed at the next inspection. This Inspection included talking to management, interviewing three members of staff no service users were spoken to on this visit has most of them were out of the home. Tour of the premises including bedrooms and sampling of records were examined. What the service does well: What has improved since the last inspection? Arrangements have been made for the manager to hold a budget to purchase equipment and usually renewal required by the home. The Commission for Social Care Inspection has also received of Regulation 26 visit reports completed by the Registered Provider. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 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 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 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 standard(s) None of these standards were assessed at this Inspection. EVIDENCE: Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 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 standard(s) 10 Information about service users is handled in accordance with the home’s written policies and procedures and the Data Protection Act 1998. EVIDENCE: Induction training for staff includes the home’s policy on confidentiality and the Data Protection Act. Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 10 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 standard(s) 12 13 14 15 Staff ensures that service users have access and take part in fulfilling activities, and participate in local community activities. EVIDENCE: As service users progresses and reassessments take place the aim of helping an individual achieving as much of their potential as possible is always under consideration. Each service user progresses at their own speed and their service user plans reflect the immediate work required but longer-term goals of employment/educational opportunities are not overlooked, and some service users currently attend college. Staff at the home ensures that individual service users enjoy the facilities of their immediate location of the home, and encourage outings to local shops, libraries, pub and churches if requested. Activity plans were seen, which shows a range of leisure activities for service users is planned, some of these take place off site or in the evening and at weekends, and all service users are risk assessed with regard to the different events and venues that they visit. All service users have access to a day centre owned and operated by the owner of the home, this is at Temple Hurst and as been opened since January Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 11 2003. Access is on an assessed needs basis and time spent there is based on the individual’s ability to participate and mix 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. 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 e.g. bank holidays. The home also arranges to take service users on holidays this is usually in small groups and for a few days at a time. The home is also in touch with any advocates appointed for service users and this involvement is recorded in individual plans. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 12 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 Service users health care needs are met through appropriate access to health care services, and personal support that meets individual service users needs. EVIDENCE: The routines that promote dignity and privacy were discussed with staff that was interviewed. Staff state wherever possible they promote privacy and dignity along with independence in carrying out personal hygiene or toilet tasks. Choice is given at all times but where choice is ignored or rejected by a service user the staff are provided with guidance in achieving the desired goal in a non-confrontational manner that will not provoke anxiety for service users. Service users health care needs are met through appropriate access to health care services that include, epilepsy services, dentist, chiropody and optical services. Some service users have access to local psychiatrist, but gaining this service on a regular basis for service users continues to be a problem for the home, however the home has acquired the services of a psychiatrist specialising in Autistic Spectrum Disorders, and will see all service users at the home if any mental health problems arise. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 13 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 23 Staff and management have a good understanding of Adult Protection and robust polices are in place to protect service users. EVIDENCE: The home has a complaint procedure, which explains who to speak to; this is available in the service users guide. Complaints records were checked and evidence was seen that any complaints received had been fully investigated and action taken. The home has an adult protection policy and procedure for staff to follow. Staff interviewed confirmed they were aware of the homes policy and procedures and could give examples of what whistle blowing was and when they would use this, they also confirmed they had recently had training in abuse and its prevention. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 14 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 25 30 Service users live in a clean, 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 staff report any problems or concerns. Evidence was seen that these repairs are documented when reported and completed. A number of windows have wood rot, and are being replaced, but this is a slow process, as they all have to be individual made. Tour of the home found it to be a clean, tidy and comfortable environment for service users. Furniture and fittings within the home area replaced on a regular basis .All lounge areas require carpets replacing and the home are looking at a more suitable floor covering for these areas. It was also identified that some corridors require carpets replacing. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 15 All service users within the home have single bedrooms; four bedrooms were seen one on each unit, those seen met the individual service users needs. Laundry facilities are on site in a central laundry and staff on each unit is responsible for service users laundry. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) None of these standards were assessed at this Inspection. EVIDENCE: Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 17 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 41 42 43 Service users live in a home that is managed by a competent and accountable manager that tries to run the home in the best interest of service users, and ensures so far as is reasonably practicable the health, safety and welfare of service users are promoted and protected. EVIDENCE: Auditing systems in place at the home and evidence was available that homes programme co-ordinator audits care plans within the home and outside pharmacist complete medication audits. The manager stated that questionnaires have been recently sent to family’s to seek their views, however the management feel any issues or concerns are usually highlighted in reviews, and they do speak to parents when they visit. Records seen were up to date and accurate; Regulation 26 visits had been completed, with the exception of some not being signed. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 18 The home employs the services of Lloyd’s employment Law and Health and Safety, who visit the home and complete audits and make recommendations. They also provide advise on compliance with all legislation. Health and safety was discussed with the manager and records examined, and observation of the homes safe working practices, all of which was satisfactory. Since the last Inspection the manager holds a budget to purchase any equipment or items required when needed. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 19 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 x x x x 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 x x Standard No 31 32 33 34 35 36 Score x 2 x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beech Tree Hall Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x 3 x 2 3 3 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. 3. 4. Standard YA24 YA24 YA24 YA41 Regulation 23(2)(b) 23 23 26 Timescale for action Premises; 31st 1)Contiue to Replace windows January that have wood rot. 2006 2) replace carpets in corridors 1st that were identified. November 2005 3) replace all lounge carpets with 31st suitable floor covering that has December been agreed by CSCI 2005 Regulation 26 reports must be 1st October completed ,signed and sent to 2005 the CSCI Requirement 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 by 2005 by encouraging and supporting staff to acquire the appropriate level 2 NVQ qualification. Beech Tree Hall 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 21 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk 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 20050825 Beech Tree Hall X10023 UI Stage 4 S8012 V214613 J55.doc Version 1.40 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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