CARE HOME ADULTS 18-65
Beechdale 302 Golden Hill Lane Leyland Lancashire PR5 1YH Lead Inspector
Val Turley Announced Inspection 21st September 2005 09:30 Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 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 Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 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. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Beechdale Address 302 Golden Hill Lane Leyland Lancashire PR5 1YH 01772 452924 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) Dalesview Partnership Mrs Hayley Elizabeth Stringfellow Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. The home is registered for a maximum of 7 service users of the category LD - (Learning Disability). The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Staffing must be provided to meet the dependency needs of the service users at all times and will comply with any guidelines which may be issued through the Commission for Social Care Inspection regarding staffing levels in care homes. 13th January 2005 Date of last inspection Brief Description of the Service: Beechdale is a detached bungalow situated on a main road approximately 1 mile from the town of Leyland, which can be accessed via a well-served bus route. Accommodation comprises 7 bedrooms, 4 with ensuite facilities, a separate bathroom, lounge, dining room, and kitchen. There is an enclosed paved patio area to the rear of the home, which contains two outbuildings one of which is a laundry room; the second has been converted into a ‘lifestyle’ (sensory) room. Beechdale provides care for service users who require short-term admission to a care home. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over one day in September 2005 by one regulation inspector. The inspection involved discussion with and observation of one of the service users who lived at the home and also discussion with and observation of the staff working there, an examination of records, policies and procedures and a tour of the premises. As part of the inspection, the inspector used “case tracking” as a means of assessing some of the National Minimum Standards. This process allowed the inspector to focus on one of the service users living at the home. All records relating to that individual are inspected along with the room occupied at the home. The service user was invited to discuss his experiences of the home with the inspector. What the service does well:
The home had a thorough pre-admission assessment process in place and the information collected as part of this process was used as the basis for the development of a care plan. Service users were encouraged to contribute to this process as far as possible to ensure that plans were appropriate. The home ensured that service users health care needs were assessed and addressed where this was appropriate for individual service users. The home arranged appropriate home based and community based activities and encouraged and supported service users to participate in these. Visitors were made to feel welcome at the home with service users being supported to receive and entertain them. The home was clean comfortably furnished and well maintained for the benefit of both service users and staff and was well placed to enable the service users to access local facilities. The home had a thorough staff recruitment procedure, protecting as far as possible the protection of service users. Staff took advantage of a variety of training opportunities and undertook all mandatory training. Training was linked to the support needs of the service users ensuring as far as possible that they received appropriate support. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 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 Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 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 The pre-admission process was in sufficient detail to ensure that prospective service users supports needs are fully assessed before admission. EVIDENCE: The file of a service user recently admitted to the service was examined. Information from the service users previous placement and information from the service user had been used to assess the suitability of the placement and provided the basis for the development of a care plan. The service user was observed to provide information to the staff about their support needs on the day of the inspection and staff discussed these with the service user in some depth and discussed future plans based on the information provided. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 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): 6 and 9, The home had adopted an effective approach to developing the care plan of one of the service users giving time for them to make decisions independently regarding support preferences. Procedures were not always followed to ensure that all activities were risk assessed to ensure as far as possible the safety of the service users. EVIDENCE: The care plan examined contained the basic support needs of the service user in detail enabling staff to provide essential support appropriately. The plan also included information provided by the service user regarding their interests and hobbies and the service user stated staff had provided support to enable these to be followed. From observation on the day of the inspection and from discussion with the manager it was clear that the service user was being given time to settle into the home and to make decisions as the placement progressed as to any additional support required. The service user appeared to be comfortable with this approach and was able to give support staff information regarding interests, likes and dislikes during conversations with them. The service user stated ‘I like living here, the staff are my friends.’ It was clear from documentation that issues of challenging behaviour were handled sensitively. Appropriate risk assessments had been undertaken in
Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 Page 10 detail in respect of the moving and handling although an assessment regarding the use of bed rails had not been undertaken, potentially compromising the safety of the service user. The manager stated that additional risk assessments would be undertaken as the service user became involved in other activities to ensure that they could be enjoyed safely. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 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): 12 and 15 The home arranged a variety of activities that were appreciated by the service users although these should be reviewed regularly to ensure that they meet the needs of the service users. Service users were supported to maintain friendships and relationships, giving them opportunities to develop personally and socially. EVIDENCE: There was written evidence within the home that a programme of activities had been arranged. This was confirmed by one of the service users who said she had attended a treasure hunt recently. Her inclusion in the activity had also been recorded in her file. Information provided by one of the service users and from a relative suggested that the activities could be improved. The manager of the home stated that service users were supported to maintain family links and friendships and that this was done as sensitively as possible, taking into account individual circumstances. On the day of the inspection one of the service users was entertaining a visitor and the staff were observed to actively support her to help make the visit successful. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 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 the following standard(s): 19 The staff worked hard to ensure that the health needs of the service users were being met however additional work could be undertaken to ensure as far as possible that their health was being monitored and any concerns addressed. EVIDENCE: Discussion with support staff and the service user and evidence on the service users file indicated that individual health care needs were being assessed and addressed, with a number of appointments with health professionals having been made or discussed. It was recommended that a health action plan be put in place for each of the service users who had a longer term placement to ensure as far as possible that the service users health care was assessed holistically and any concerns addressed. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 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 the following standard(s): 22 Information about the homes complaints procedure was not consistent leaving service users and staff with different guidance as to the different ways in which a complaint could be made. EVIDENCE: The homes service users guide contained a clear complaints policy, using illustrations to help service users understand. It was also available on audiotape, ensuring as far as possible that most service users would find the information accessible. No complaints had been made to the service since the last inspection. The information within the complaints policy contained slightly different information and this should be reviewed to make it clear that complaints can be made to the Commission for Social Care Inspection at any stage. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 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 the following standard(s): 24 The home was clean and comfortably furnished, providing a safe and homely environment for both service users and staff. EVIDENCE: The home was bright, clean and airy and was comfortably furnished providing a homely atmosphere for the service users. The home accommodated a number of service users who used a wheelchair and the home provided level access to all areas. In addition to the living accommodation the home also had a sensory room which all of the service users could access, enabling them to pursue specific activities or spend time there alone. The home was situated close to the local town and facilities and service user were supported to visit these. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 Page 15 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): 34,35 The home had a thorough recruitment procedure in place, which ensured as far as possible the protection of the service users. Training in the administration of some medications was not thorough enough, potentially leaving some service users at risk. EVIDENCE: The file of two members of staff was examined and the homes recruitment policy and practice was discussed with the manager. The files contained all of the necessary documentation, which indicated that the homes recruitment policy was thorough and so ensuring the protection of the service users as far as possible. Although there had been no new staff appointed in recent months, discussion with the manager indicated that she had an awareness of the procedures to follow in terms of the relevant checks that must be made on new employees. National Minimum Standards 35 was not fully assessed at this inspection, however discussion with the manager indicated that regular training by a health professional in the administration of some medications had not taken place. This potentially left the service users at risk. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 Page 16 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): 42 The homes policies and procedures in respect of maintaining the health and safety of the service users needed to be reviewed to ensure the protection of service users. EVIDENCE: The home was well maintained with evidence that systems and equipment had been appropriately serviced. The homes training matrix indicated that staff received mandatory training in safe working practices. Certificates on staff files confirmed this, as did discussion with staff. This approach ensured as far as possible the safety of both service users and the staff. The information provided in respect of fire policies and procedures was inconsistent with different guidance being provided in different documents. The manager recognised the need to consult with the Fire Service to ensure that appropriate policies and procedures to protect service users were in place bearing in mind the level of disability of some of the service users using the home for respite care. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 Page 17 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 3 X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 2 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Beechdale Score X 2 X X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000005928.V252681.R01.S.doc Version 5.0 Page 18 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 YA9 Regulation 13(4)(c) Requirement Unnecessary risks to the health or safety of the service users must be identified and so far as possible eliminated. The registered person must establish a consistent complaints procedure. The registered person must ensure that support staff receive training appropriate to the work that they are to perform The registered persons must consult with the fire service to ensure that relevant policies and procedures are appropriate for the home and the service user group. Timescale for action 31/10/05 2 3 YA22 YA35 22 18(1) 31/10/05 31/12/05 4 YA42 23(4) 30/11/05 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 YA12 Good Practice Recommendations The home should regularly review its activities programme to ensure its appropriateness for all service users.
DS0000005928.V252681.R01.S.doc Version 5.0 Page 19 Beechdale 2 YA19 Health action plans should be developed for each of the service users who have a longer-term placement. Beechdale DS0000005928.V252681.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Chorley Local Office Levens House Ackhurst Business Park Foxhole Road Chorley PR7 1NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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