Inspection on 09/05/07 for Beeches (The)

This inspection was carried out on 9th May 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beeches (The) 29/04/09

Beeches (The) 31/01/06

Beeches (The) 14/06/05

Beeches (The) 23/11/04

Beeches (The) 06/05/04

Beeches (The) 18/03/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Beeches (The) The Beeches 48 The Drive Ilford Essex IG1 3JF Lead Inspector Ms Harina Morzeria Key Unannounced Inspection 9th May 2007 10:00 Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beeches (The) Address The Beeches 48 The Drive Ilford Essex IG1 3JF 020 8518 3704 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) thebeeches48@onetel.com Dr Chanan Singh Sidhu Ms. Linda Morris Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Beeches is registered for 8 adults with a Learning Disability and Associated Mental Health Problems. 31st January 2006 Date of last inspection Brief Description of the Service: The beeches is registered to care for younger adults with moderate learning disabilities and associated mental health problems. The home is situated on a busy main road in a residential area in the London Borough of Redbridge. It is within easy reach of a park and the main town centre in Ilford which is accessible by public transport. All service users occupy their own single rooms which are well furnished and decorated. The service users are supported by the manager and staff to maintain their independent living skills, go to the day centres, attend college for various courses as well as accessing community facilities locally. Some residents access day services, others are supported in community based activities by the staff team. Service users are also encouraged to work part time in paid jobs or work as volunteers in charity shops if they wish. Activities are organised both within the home and via various club memberships. Personal care is provided on a 24-hour basis, and all health care needs are met by staff supporting service users to attend appointments with health professionals. The fees for the home range from £700.00 -- £900.00 per week. A copy of the Statement of Purpose and Service User Guide are available in the home, together with a copy of the most recent inspection report. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection visit in the inspection programme for 2007/2008 and was an unannounced inspection. The registered manager was available during the visit to aid the inspection process. Discussion took place with the manager, deputy manager and two members of care staff, who were asked about the care that residents receive, and were also observed carrying out their duties. The inspector was able to talk to the residents living in the home and asked their views on the service and their experience of living in the home. A tour of the home was made and some bedrooms were viewed. Residents files were viewed, together with examination of staff and other home records, including medication administration, accident/ incident records, staff rotas and staff recruitment files. Information was also taken from a preinspection questionnaire completed by the manager. The inspector would like to thank the residents and staff members for their input during the inspection. What the service does well: What has improved since the last inspection? What they could do better: Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 6 A very good service is given to the residents and the house is, in general, comfortable. Some areas of the home and garden require de - cluttering and re-arranging to make the space more user friendly. Outstanding general maintenance work needs to be carried out, which the manager is aware of. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 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 Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The Statement of Purpose and Service User Guide provide prospective residents and their relatives/ representatives with all the information they need to enable them to make an informed choice about whether they wish to live in the home. Assessments undertaken by the home and the information and reports received from health and social care professionals means that staff have detailed information to enable them to determine whether or not the home can meet a prospective residents’ needs. Residents have individual contracts or a statement of terms and conditions with the home, so that they are clearly aware of the services that the home can offer. EVIDENCE: The home has a Statement of Purpose and Service User Guide. These are informative, well presented and provide residents and their representatives with a good understanding of the service and facilities. All people who use the service are given a copy of the Service User Guide. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 9 There are currently no vacancies at the home. A number of the residents have lived in the home since it first opened. Two new residents were accommodated last year. Admissions are not made until a full needs assessment had been undertaken. The assessment is conducted professionally and sensitively by the manager or the deputy and involves the individual, and their family or representative where appropriate. Where the assessment has been undertaken through care management arrangements the service insists on receiving a summary of the assessment and a copy of the care plan. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective resident. From viewing pre-admission assessments/ documentation it was evident that a full assessment is undertaken, prior to the admission of any resident to the home. There is always a planned, phased in introduction to the home and the other residents. The length of this process would be dependant on the individual’s needs. Each resident has a Contract, which sets out in detail what is included in the fee, the role and responsibility of the provider, and the rights and obligations of the individual. There was evidence to show that where capable, residents and/ or their representatives had signed the contract. The Care Homes Regulations 2001 have been amended with effect from the 1st September 2006 for new residents, and for existing residents with effect from the 1st October 2006, so that more comprehensive information is to be included in the Service User Guide. Details of information to be included are contained within the amended regulations. Therefore, the Service Users Guide must be reviewed and amended by the stated timescales. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7, 8, 9 & 10 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans are detailed and provide staff with the information they need to satisfactorily identify and meet residents personal, social support and health care needs. The home maximises independence wherever possible and staff provide residents with information, assistance and support to make decisions about their own lives. Residents know that the staff handle information about them appropriately, and their confidences are kept. EVIDENCE: The service involves individuals in the planning of care that affects their lifestyle and quality of life. Staff understand the importance of residents being Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 11 supported to take control of their own lives. Individuals are encouraged to make their own decisions and choices. The care plans are person centred and agreed with the individual. Individual files were available for each resident and the records of three residents were case tracked. Care plans are developed for each resident following the principles of person centred planning and each resident has a plan that has been agreed with them. It identifies needs, likes, dislikes and considers all areas of the resident’s life including health; personal and social care needs. Staff support and encourage residents to be involved in the ongoing development of their plan. Each resident has a separate health plan and a daily communication diary. A key worker system allows staff to work on a one-to-one basis and contribute to the care plan for the individual. The care plan is a working document reviewed regularly involving the person, key worker, a representative and where agreed, their families. Each care plan includes a comprehensive risk assessment, which is reviewed regularly. Management of risk is positive addressing safety issues whilst aiming for better quality of life. When limitations are in place, the decisions have been made with the person and are recorded. The inspector viewed the risk assessments of the people who were case tracked and noted that these focused on maintaining and promoting residents’ independence whenever possible, and individual staff were observed providing residents with information, assistance and support and were respectful of their right to make decisions. There are procedures in place to ensure that people using the service are informed of their right to confidentiality. Individuals understand when staff may have to share personal information and can access advocacy services for support. The manager is aware of current policy issues and good practice developments, keeping up to date with new information and cascading this to the staff effectively. The home ensures that residents are consulted on a regular basis to gather information about their satisfaction with the service and care provided. They are involved in both the development and review of the service as much as practicable for example, two residents were consulted about developing the home’s policy and procedure regarding the missing person’s and smoking policies. This has meant that the residents own them and understand the importance of adhering to them. Residents also regularly join in for part of the staff meeting, making contributions when planning activities, outings and daily living issues. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Standards 11, 12, 13, 14, 15, 16 & 17 Opportunities for social and leisure pursuits and personal development are actively promoted and supported by staff, for all residents to enable them to participate in the wider community in which they live. Residents have appropriate relationships and their rights are recognised in their daily lives. Residents are offered a varied and balanced diet and are consulted about their choices of food and participate in shopping. EVIDENCE: Each resident has a planned activity programme, which takes account of the resident’s preferences, interests, experiences, age and capabilities related to their disability. The home has sought the views of the residents and considered their varied interests when planning the routines of daily living and arranging activities both in the home and community. Routines are very Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 13 flexible and residents can make choices in major areas of their life. The routines, activities and plans are resident focused, regularly reviewed and can be quickly changed to meet individuals’ changing needs, choices and wishes. This was observed on the day of the inspection when one resident decided she did not want to go to the day centre which was entirely her choice. Later the residents chose whether to go out for lunch or stay in. Through discussion with staff and viewing activity programmes, the inspector was able to evidence what social and other activities residents are involved in. This included attendance by one resident at college for drama and IT skills independently using public transport. Other residents attend a day centre and social clubs with friends and staff. One resident works in the cafeteria on a part-time basis at a local day centre. Some residents attend specialist day centres and others have programmes of activities in the home being managed/ supervised by staff. All residents are supported to participate in leisure activities in the community, both specialist and mainstream for example, one resident enjoys karaoke and is regularly goes to a pub where this activity takes place. Residents have an annual holiday or short breaks/ days out together or in small groups. Just before the inspection the whole house had been on holiday to Gran Canaria and all had “a really good time”. Other day trips, which have been planned by the residents include going to France, Belgium, the Cotswolds. Residents have the opportunity to develop and maintain important personal and family relationships and are able to access information on specialist guidance about issues such as intimate relationships. Residents regularly go out with their friends and family including overnight stays. The practice of staff promotes individual rights and choice, but also considers protection of individuals, supporting people to make informed choices. Where appropriate residents are involved in taking some responsibility for their own room. One resident said: “ I look after my own room, but staff need to help me sometimes”. All the residents spoken to said that they were “happy” living in the home and they felt staff looked after them well. During the inspection, the residents were observed accessing all areas of the home independently. The home has limited facilities for private meetings but residents are able to use their bedrooms. Those residents spoken to stated that they liked the food and there is sufficient choice. The staff prepare and cook meals with some involvement from the residents and staff know what each person likes to eat. During the visit, the inspector checked the menus. A variety of food is available which included meat, fish, dairy produce; and fresh fruit and vegetables. Mealtimes are flexible and relaxed. The residents appreciate the support and guidance about a balanced healthy diet and this was reflected in the improved weight management and associated health benefits enjoyed by the residents. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 14 Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 & 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents receive personal support in the way they prefer and their physical and emotional needs are closely monitored to ensure that their needs are recognised and met. There are clear medication policies and procedures for staff to follow. EVIDENCE: All of the care and health plans examined, clearly recorded referrals to specialist health care professionals and that appointments were being kept. Records indicated that residents have attended routine health appointments including GP, dentist and chiropodist and see consultants for specific health concerns. Residents have regular reviews of their medication undertaken by their GP. Staff have access to training in health care matters and are encouraged and given time to attend seminars/training on specialist areas of work. Hence, staff are alert to residents’ changes in mood, behaviour and general well being and fully understand how they should respond and take action. The aims and Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 16 objectives of the home reinforce the importance of treating individuals with respect and dignity. There was evidence that support is in place to help residents with their personal care. Staff were observed to be providing residents with sensitive and flexible personal support and all such support is provided in private. Residents are supported and helped to be independent and can take responsibility for their personal care needs. Residents spoken to confirmed that they are happy with the support they receive around personal care needs. There are policies and procedures in place for the handling and recording of medication. Medication is stored in a locked medicine cupboard in the office and is appropriate to ensure the safekeeping of medicines in the home. An audit was undertaken of the management of medicines in the home and Medication Administration Record (MAR) charts were examined. None of the residents are currently able to self medicate. Only staff who have completed and passed appropriate medication training administer medication. An assessment has been carried out to ensure each member of staff is competent to handle, record and administer medication properly. This was evidenced on staff training records examined during the visit. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 22 & 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager and staff make every effort to sort out problems and concerns by acting upon and resolving any issues. All staff working in the home have received training in adult protection/ abuse awareness to ensure that there is a proper response to any suspicion or allegation of abuse. EVIDENCE: There are policies and procedures for dealing with complaints, which is accessible to the resident group. The complaints procedure is clearly displayed throughout the service and is given to all other involved agencies or professionals in the local community. The inspector spoke to three residents about what they would do if they were unhappy with anything. All three residents said: “I would speak to the manager (Lynn) or one of the staff”. One resident has a named advocate, who visits her regularly. The complaint log was examined and this recorded the number of complaints/ concerns, action taken and the outcome for the complainant. The manager also ensures that staff routinely record all verbal issues of concern or dissatisfaction expressed, and all such concerns have been acted upon and resolved. The home learns from complaints in order to improve its service. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 18 There is a written policy and procedure for dealing with allegations of abuse and whistle blowing. All staff have received training in adult protection/ abuse awareness, and this is included in the induction training for all new staff. Those staff spoken to during the inspection, were aware of the action to be taken if there were concerns about the welfare and safety of residents. People using the service and all their representatives are made aware of what abuse is and the safeguards in place for their protection should they need them. Access to external agencies or advocacy services is actively promoted. The home is clear when an incident should be referred to the Local Authority as part of the local safeguarding procedure. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 24, 25, 26 & 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The premises are homely and the atmosphere in the home is very welcoming. The living environment is appropriate for the particular lifestyle and needs of the residents and is clean, safe and comfortable. EVIDENCE: The home was toured at the start of the inspection, and all areas were visited by the inspector, accompanied by the manager. All the bedrooms are single. Two bedrooms are located on the ground floor. All the upstairs bedrooms were visited by the inspector. These rooms were furnished and decorated to suit individuals’ preferences and particular needs; and are reflective of their interests and lifestyles. The whole house has been re-painted. New carpets and some furnishings have been purchased for the living room. The residents were fully involved in decisions about the décor and any changes to the accommodation. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 20 The inspector noted that some areas in the house are yet to be de - cluttered and re-arranged which has been discussed with the manager. The small room used by staff also needs to be re-organised and food must not be stored in this area. It was noted that the lock in the upstairs bathroom door was damaged and residents would be unable to lock the door when using the bathroom. This was brought to the attention of the manager who said she was not aware that the lock was broken and would report the lock for repair as a matter of priority. The carpets in the upstairs toilet needs to be replaced as it was discoloured. The downstairs bathroom also needs to be “modernised” and made into a warm, welcoming and pleasant area. All areas of the home were generally clean, tidy and free from odour throughout. There is a small utility room (being re-furbished), which residents are able to use with the support of staff. There is a small garden at the back which was being reorganised and cleared of clutter to enable the residents to enjoy it in the summer. The staff and manager also hope to make the conservatory a user friendly space for the residents. There is a good infection control policy and staff are encouraged to work to the home’s policy to reduce the risk of infection. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staffing levels are satisfactory and there are sufficient staff on duty to meet the individual assessed needs of the residents. The procedures for the recruitment of staff are robust and provide safeguards for people living in the home. EVIDENCE: There are consistently enough staff available at all times to support the needs, activities and aspirations of the people using the service. More staff are available at peak times of activity and during outings. Rotas show well thought out and creative ways of making sure that the home is staffed efficiently. In discussion with staff on duty it was evident that that they understand and fully support the main aims and values of the home. Through discussion with residents and observation of staff interaction with individuals, it is evident that they have confidence in the staff that care for them, and that staff have a good understanding and knowledge of the particular needs of the residents. Staff were seen to have the skills to communicate effectively with all residents. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 22 The staff files of the most the most recently recruited people were examined. These were found to be in good order with the necessary references; Criminal Records Bureau (CRB) disclosures and application forms duly completed. Accurate job descriptions and specifications define roles and responsibilities of staff. Staff members undertake external qualifications beyond the basic requirements. The manager encourages and enables this and recognises the benefits of a skilled, trained workforce. Staff files showed that staff had undertaken essential training in first aid; fire safety; food hygiene; health and safety; manual handling and adult protection. Other training planned includes mental health awareness. The pre-inspection questionnaire completed by the manager states that 90 of care staff are qualified to National Vocational Qualification (NVQ) level 2 or above. All the seniors have completed their NVQ Level 3 qualification with one person completing it. The deputy manager is completing her NVQ Level 4 and RMA qualifications. Staff records show that all staff have regular supervision and appraisal, and staff meetings are held monthly with written minutes being kept. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41, 42 & 43 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home is efficiently managed, residents interests are safeguarded and they benefit as the home is run in their best interests. EVIDENCE: The current manager is registered and is well experienced to manage the home. She demonstrates a clear understanding of the needs of the residents. It was very evident that the home is operated for the benefit of residents, and every effort is made to retain the independence of those people living in the home and for them to exercise choice and control over their lives. The dependency levels of the current resident group are very variable, and are well considered by staff when providing the level of assistance and support needed by the individual resident. Staff spoken to has stated that the manager is very a imaginative and effective leader, who consistently encourages them and provides support to offer innovative ways of working with the residents. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 24 She enables them to undertake regular training and understanding offering them new opportunities to continue their own professional development. Evidence was seen that practice and performance issues are discussed during supervision, staff training and team meetings. Spot checks on quality and monitoring systems provide management evidence that practice reflects the homes policies and procedures. The views of both the residents and staff are listened to and valued. There are clear lines of accountability. The insurance cover in place ensures that the home is fully insured to meet any loss or legal liabilities. The home provides sufficient assistance to ensure effective safeguarding and management of individuals money including record-keeping. Currently the manager does not act as an appointed agent for any resident. Four residents manage their own financial affairs, and the others are managed by their relatives/ representatives. The home has responsibility for the personal allowances of residents and secure facilities are provided for their safekeeping, with records being maintained. The proprietor undertakes monthly Regulation 26 monitoring visits to monitor and report on the quality of the service being provided in the home. A copy of the report is sent/ made available to the Commission. Record-keeping is of a consistently high standard. Records are kept securely and staff at aware of the requirements of the Data Protection Act. People who use the service can gain access to their records and contribute to them. The home has a comprehensive range of policies and procedures to promote and protect residents and employees’ health and safety. The manager of ensures that all staff are trained in health and safety matters and individual training records reflect this and regular updates are planned. There is full and clearly written recording of all safety checks and accidents, and the manager complies with the statutory reporting requirements and other relevant legislation. The manager, senior staff and staff at all levels have a good understanding of risk assessment processes and this is taken into account in all aspects of the running of the home. Health and safety systems are regularly reviewed and updated and developed on the basis of experience in the home and learning from external developments. Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 25 Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 26 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 4 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 X 3 X 3 3 3 Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beeches (The) DS0000028719.V339252.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Ilford Area Office Ferguson House 113 Cranbrook Road Ilford IG1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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