Inspection on 25/06/07 for Beechwood

This inspection was carried out on 25th June 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechwood 27/04/06

Beechwood 31/10/05

Beechwood 23/06/05

Beechwood 10/05/05

Beechwood 29/11/04

Beechwood 08/09/04

Similar services:

Thorndene

Insight - Eastchurch

Southfields

Magenta

Seabourne House

33 St John`s Church Road

Dovedale Court

Lyncol House

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

CARE HOME ADULTS 18-65 Beechwood The Lodge High Pitfold Hindhead Surrey GU26 6BN Lead Inspector Helen Dickens Unannounced Inspection 25th June 2007 10:45 Beechwood DS0000013702.V339296.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 Beechwood DS0000013702.V339296.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. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechwood Address The Lodge High Pitfold Hindhead Surrey GU26 6BN 01428 608124 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) Robinia Care South Limited Kathryn McInnes Care Home 6 Category(ies) of Learning disability (0), Sensory impairment (0) registration, with number of places Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be 17 - 25 years. Date of last inspection Brief Description of the Service: Beechwood and The Lodge are both part of the Robinia Care Group. The Southern Region Organisation specialises in services for people with learning disabilities and challenging behaviours. The homes are located on the Robinia South Old Grove site, just off the A3 South of Hindhead and situated on a small complex of largely purpose built single storey buildings, one providing day care (The Grove) and the remainder are residential. Beechwood is a five-bedroom bungalow and The Lodge is a two-bedroomed bungalow with one service user, supported by two members of staff over a twenty-four hour period. The Lodge is registered for one service user only. Beechwood and The Lodge are staffed independently of each other with the Registered Manager overseeing the two homes. Each of the homes has its own communal facilities and enclosed secluded gardens with adjacent parking. The service users all present with challenging behaviours. Weekly fees range from £1,224 to £4,765 per person per week. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 7.5 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The Registered Manager, Kathryn McInnes, represented the establishment. A partial tour of the premises took place. The inspector spoke briefly to five residents and observed their interactions with staff throughout the day. Six ‘comment cards’ returned to CSCI, and the Annual Quality Assurance Assessment completed by the manager were also used in writing this report. Three resident’s care plans and a number of other documents and files, including two staff files, as well as risk assessments and maintenance records, were examined during the day. The Commission for Social Care Inspection would like to thank the residents, manager and staff for their hospitality, assistance and co-operation with this inspection. What the service does well: What has improved since the last inspection? Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 6 All the Requirements made at the last inspection have been met including updating the Statement of Purpose and ensuring all residents have contracts. Documents and other records are now kept securely and all documentation relating to the administration of medication is now well-kept. The local children and adults safeguarding policies have been made available to staff as required at the last inspection – the policies are in a bright red folder in the office and each staff member has signed to say they have read and understood them. In addition the manager has introduced a large print laminated reminder in the front of each resident’s care plan to highlight to staff exactly what they must do if there is a suspicion of abuse. The Recommendation to provide a more user-friendly format for the complaints procedure has been done and, in addition, a further six policies relevant to residents have been translated into similar formats. A new ‘Welcome to Beechwood’ handout sets out the ethos and objectives of the home. The new manager has introduced key-holder guidelines for staff regarding who holds the keys, and the handover sheet records who the medication keys were passed to on each shift. All staff have done safeguarding children training in order to admit one resident who is under 18 years old. The role of the key-worker has been formalised and six important support areas have been identified and this is posted in the office and on resident’s files. All residents now have their goals documented on their care plans. What they could do better: Only two Requirements were made as a result of this inspection. The first concerns obtaining more detailed guidelines for staff to use when administering ‘as required’ medication. The second concerns some health and safety matters which are detailed in the final section of this report. Two Recommendations were also made including adding the educational history and attainments of one service user to their care plan, and reconsidering the policy not to offer refresher training on safeguarding adults and children. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 7 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. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective resident’s individual aspirations and needs are thoroughly assessed prior to them moving into this home. There is a high level of involvement from the resident and their family in this process. EVIDENCE: Two resident’s files were examined and pre-admission assessments are carried out by the Development Manager for Robinia, and also by the registered manager for the home. There was a good level of detail in the assessments including information about all the support needed including personal care and communication. One resident who was recently admitted had more detailed assessments done by the registered manager who spent time with them in their school, as well as in their previous home. One resident did not have a copy of their care management assessment on file and the manager said this document was used by the development manager to carry out his assessment but not kept at the home. Following the inspection it was agreed that all assessments from care management and other professionals will be made available to the registered manager whilst she is carrying out her assessments, and a copy will be kept at the home. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 10 The service user guide and statement of purpose have been up-dated; copies are on resident’s files and copies have also been given to their parents. The manager initially tried to give one to each resident for their own room but this did not work for a variety of reasons and now these are kept on their files in the office. The previous inspection highlighted the need to include information on staff training in the home’s information guides, particularly with regard to communication, and this has now been done. The previous Requirement that the statement of purpose and service user guide reflect accurately the current client group has now also been done. All residents now have a contract of terms and conditions as required at the previous inspection. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 11 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): 6,7,8 and 9 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are reflected in their care plans and they are encouraged to make decisions within their capabilities. Staff work hard to facilitate the participation of residents in the life of the home. Residents are supported to take risks as part of an independent lifestyle. EVIDENCE: Three care plans were examined and found to contain the necessary information. Both had photographs of the resident and some parts of the plan were in an accessible format including pictures, easy words, and some symbols according to the needs of the resident. One resident joined the inspector and registered manager and briefly assisted in turning over the pages as they were examining this resident’s plan; this was encouraged by the manager as it demonstrated that this particular resident was happy for their care plan to be looked at. Each care plan contained a guidance note at the front about exactly what action to take if any safeguarding issues arose, and there is a reminder Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 12 sheet for staff about what information needs to be completed on a daily basis in each care plan. The input from other professionals including health colleagues is also included in the care plan and daily notes. The care plans were up-to-date, regularly reviewed, and completed in full. The home has one resident aged under 18 and the additional Standards relating to 16 and 17 year olds were also taken into account when assessing how well the home performs on the Individual Needs and Choices Standards. Residents are encouraged to make decisions and choices are given in relation to day to day activities, for example choosing menus which is discussed under Standard 17. There is much emphasis on the communication needs of residents and each has a ‘book’ about themselves which contains information on how they communicate, and their personal history, including photographs of family and friends. Decisions and preferences are recorded in this book, and in their care plans. Areas where decisions have had to be made in the best interests of residents are also recorded in the care plan, for example regarding resident’s ability to hold a key to their room. The residents at this home have high needs and all have difficulties with communication. Despite this, the registered manager and staff should be commended for the way they try to involve and include residents. A number of policies and procedures have been translated into more accessible formats for residents including the bathing policy; the visitors policy and the fire policy. In total there were 6 newly translated policies which the manager said are explained to residents both in resident’s meetings and with their key workers. Residents are able to take risks with appropriate support, and risk assessments were on file relating to individual residents as well as to home in general. Generic risk assessments on file include risks relating to the outside gate, the fish bowl in the living room and attending social events. The manager said she is currently reviewing all the risk assessments and these will be translated into a newer format. Those sampled were satisfactory and had been reviewed in a timely fashion. The organisation employs an occupational therapist to work with residents and one of her responsibilities is to do all the manual handling risk assessments, and to provide annual refresher training on this subject for staff. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16 and 17 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are given opportunities to take part in fulfilling activities and to be part of the local community. Family and friendship links are encouraged and resident’s rights respected. Arrangements for meals and mealtimes encourage resident choice and participation. EVIDENCE: Robinia provide activities on the site in Hindhead which means all residents at Beechwood have access to a number of facilities and opportunities near their home. Though none of the residents are able to work, a range of interesting and fulfilling activities are available. There is a physiotherapist and occupational therapist employed at the Day Centre and residents have access to the gym. There is trampolining and other exercises, as well as more relaxing pursuits in the White Room (for relaxation and sensory stimulation); and a Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 14 variety of treatments including reflexology and aromatherapy, and a hydropool. There are specialist rooms for cookery, drama and music, and arts and crafts. There is also a drumming room which the manager said was very popular with one of the residents from Beechwood. The facilities are available in the evenings and weekends when residents are accompanied by staff from the home. All residents take part in sessions at this centre except the resident who is currently in full time education; their arrangements are being reviewed and a plan drawn up for them to join some activities at the centre once they have finished at school. There are outside activities and the home now has access to vehicles for use in taking residents out. Outings over the last month involving at least some Beechcroft residents have included a meal at MacDonalds; a pub meal; and an afternoon sailing. Other outdoor activities include rambling, using the theatre in Petersfield, and going to the Saturday cinema at Gunwharf Quay where there is a special session for people with autism. Two residents from Beechwood use this facility. All outings in the home’s transport are noted in the mileage book on the minibus and residents are charged separately for this, on a per mile travelled basis. Residents are part of their local Robinia community in Hindhead and social events and outings are arranged with other service users who use the day care and residential facilities. The home also has links with the private school across the road and the manager said local people are generous at donating items for the annual fete and open day. The local theatre and cinema are used by residents as outlined above, and they also use supermarkets, pubs and restaurants. Family relationships are encouraged and staff spoken to were knowledgeable on resident’s families. Visitors are encouraged and visiting times are open and flexible though the manager encourages relatives to ring in advance to check that someone is going to be at home. All family visits and contacts are noted on the daily events sheet on resident’s care plans. Information regarding personal relationships was noted on resident’s files. Residents were observed to be treated respectfully by staff and there were no instances during the inspection were staff were interacting with each other to the exclusion of residents. There were several instances were staff broke off their discussion in order to include a resident who had joined them. Residents could choose whether to join in with activities or not and their bedrooms were arranged with sufficient comfort and interesting items to give them an alternative venue if they wished to be alone. The manager should be commended for the arrangements now in place for resident’s meals. Each Sunday a member of staff uses a home made catalogue full of pictures of hundreds of food items to encourage residents to be involved in food choices. Residents who are able to, will point to their food preferences, Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 15 and the manager said more tactile objects such as pasta can be tried with the resident who has a sensory impairment. Menus are then chosen for the week – and there are guidelines for staff about shopping. Information relating to food and nutrition is clearly documented on care plans including food preferences and dislikes, and what has been provided for residents on any given day. The manager said frozen vegetables are only used in emergencies and they do not buy cook chilled foods. Resident’s weights are regularly recorded and one resident who had apparently lost weight was given additional support in a timely fashion. The manager could not find a record of when the Borough Council’s environmental health officer last visited the property or looked at the kitchen, and she was asked to follow this up with them. There are a number of extra Standards relating to people aged 16 and 17 under this section, and the manager was aware of these and gave examples of how she felt the home was meeting the needs of one resident who is under 18. The educational history and attainments of those under 18 should be included in their individual plan and the manager said she would do this as this information was available elsewhere on that residents file. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 16 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): 18,19 and 20 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s receive personal support in the way they prefer and require and their health needs are met. There are good arrangements in place for the administration of medication. EVIDENCE: Resident’s care plans contain a good level of information about how they would like to be supported when receiving personal care. This information has been compiled both from their original assessments and from observations of staff when carrying out personal care tasks. Staff were observed to communicate well with residents – each resident having their own very individual way of communicating. Residents were dressed in a way that reflected their personality. Special equipment was available as necessary, for example one resident was assessed as needing a chair hoist for the bath and this had been purchased by the home. There are good records of health interventions with residents. There is also a separate document, based on the health action planning model, to highlight Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 17 resident’s health needs. These are in easy read formats with pictures and/or symbols according to resident’s needs. All interventions are documented and the home has good relationships with community health professionals. One GP who returned a completed questionnaire to CSCI was very complimentary about how the home is run. All staff have had training in how to administer medication delivered by a specialist company; that company have also supplied a competency test format which the manager uses to up-date staff on this subject. Medication records are checked at handover and a note is made of who the keys have been handed to. Two resident’s medication administration records were checked for the previous month and there were no unexplained gaps. There is guidance for staff on file for the administration of homely remedies and the manager is working on a pain recognition tool to better establish when a resident is in need of painkilling medication. The manager was also asked to review guidance for staff on ‘as required’ medication as more detail is needed for staff on the circumstances under which this should be given and this should be agreed by a medical practitioner. The manager was also asked to contact the local NHS Trust to check if they are entitled to a free pharmacy inspection and advice. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 18 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): 22 and 23 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s views are sought and taken into account, and they are protected from abuse. EVIDENCE: There is a complaints procedure in place at this home and a resident-friendly version available for people living at Beechwood. Returned comment cards from residents (completed with staff assistance) indicated that they would know how to complain. Staff were noted to communicate well with residents and to understand what residents needed. No complaints have been made to the Commission since the last inspection and the home’s complaints book was examined and there had been no complaints directly to the home. The home has copies of both adults and children’s safeguarding procedures and staff have a whole day of training on this subject as part of their induction. The most recent staff member to join the home had a certificate on file to demonstrate that the one day course had been successfully completed. The manager has introduced a large print reminder at the beginning of each resident’s file to remind staff exactly what they should do if there is any suspicion of abuse relating to that resident. The manager was also clear that any allegations would be brought to the attention of the local authority in the first instance. When staff files were examined it was noted that all staff have both pova (safeguarding adults) and poca (safeguarding children) list checks, to ensure they had not been found unsuitable to work with vulnerable people. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 19 There are some additional Standards relating to this subject in relation to young people aged 17 and 18 years. The manager gave examples of how she felt the home was meeting these additional Standards, including the home having a bullying policy. It was noted that Robinia do not have safeguarding training on their list of mandatory training courses. Though the initial training is a one day course, there is no other formal training on this subject following induction. This needs to be reviewed to ensure that at least refresher training is given to staff throughout their employment with vulnerable people. Residents at this home need assistance to manage their finances and all have parents or family who do this. However, the home also keeps small amounts of money for resident’s day to day expenses such as spending money for outings. Receipts are kept and all expenditure noted – two residents cash records and purses were checked and found to be correct. Residents pay for any meals eaten when they go out and £1.50 per meal is refunded to the client as Robinia’s contribution. One resident’s monies checked showed that he had eaten out twice recently and on both occasions Robinia had refunded £1.50 to his account. These records are checked by someone from the finance department on a monthly basis. When residents travel in the home’s transport a record of the mileage travelled is kept and charged to the resident. Though a record of miles travelled for all residents could be sampled on the day of the inspection, the financial arrangements for recharging residents are carried out by the finance department and no records are kept at the home. This was discussed with the manager and the following day an arrangement was made internally at Robinia that from June 2007 copies of all records relating to how mileage is charged to residents will be kept at the home and available for examination. The previous report made a requirement regarding recompense for some service users who had been overcharged regarding their transport costs. This has now been completed and two service users bank statements sampled had details of money paid in by Robinia as agreed. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 20 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): 24 and 30 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s live in a homely, comfortable and safe environment, which is clean and hygienic throughout. EVIDENCE: Beechwood offers a homely and pleasant environment for residents. Four resident’s bedrooms and all the indoor communal areas were visited as part of the tour of the premises. Individual rooms had been personalised and the manager said residents and their families had chosen colour schemes and décor. Rooms were very personalised and one bedroom reflected the favourite football team of that resident with everything including the duvet cover, the colour of the walls, and a giant player being related to the team. The premises were accessible to residents and the furnishings and fittings are of good quality and domestic in character. Some issues relating to the premises were highlighted during the inspection and the manager provided satisfactory responses in relation to remedying Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 21 these, therefore no Requirements have been made. Only resident’s bath water temperatures were being checked and the manager arranged to have other water outlets, which were accessible to residents, monitored in the same way. Three different water outlets were checked during the inspection and all were within the required range of around 43C. One wooden radiator cover which had a hole in was being replaced by a more suitable cover – this had already been reported to the maintenance department. One wall in the laundry had gel stains from the dispenser and an area where the paint had come off – the manager said this would be attended to. The laundry room was clean and tidy. There were no unpleasant odours in the home except where a recent water leak had caused some damp and this has been already been treated. There were good hand washing facilities throughout the home with individually dispensed liquid soap, paper towels and hand gel. The manager was asked to review the arrangements for the security of the hazardous substances cupboard. The following day she arranged for a self-locking device to be fitted whereby the cupboard would be locked as soon as the door was closed, rather than needing a key to lock it. A food freezer is currently in the laundry and the inspector asked that this be reviewed. As there is no record of an environmental health department visit to this home, the manager was asked to follow up on this, and highlight the issue about the freezer with them. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 22 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): 32,34,35 and 36 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent staff and protected by the home’s recruitment practices. Arrangements for staff training and supervision are good. EVIDENCE: Staff at this home were observed to communicate well with residents and were approachable and comfortable with them. The induction arrangements give staff a good grounding in caring for residents with learning disabilities. There is also specialist training available according to the needs of residents, for example on epilepsy. Staff were observed to balance the fluctuating needs of residents and were seen to anticipate resident’s needs throughout the day. The home was recently granted a Variation to admit one resident aged under 18 and the Registration report from CSCI stated that Robinia had undertaken to provide an additional member of staff with an NVQ3 in childcare until the resident reached 18. The new manager was unaware of this undertaking and the planned secondment of a member of staff from another home had not Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 23 taken place. Following the inspection the manager established with head office at Robinia that the secondment could not go ahead due to the timing of the placement and the circumstances of the member of staff who was to be seconded. CSCI had not been made aware of this change in arrangements. The manager said the alternative back-up arrangement was access to advice from another home manager who ran a children’s home for Robinia. The new manager also has a GNVQ in health and social care which included the care of children. Two recruitment files were sampled and found to be well kept with all the correct documentation including Criminal Records Bureau checks and pova and poca list checks to ensure staff have not been listed as unsuitable to work with vulnerable adults or children. Both files had an application form with a full employment history and references, photographic identification and copies of driving licences. There is a training and development plan in place and good records of staff training. Those staff files sampled showed both had had all the mandatory training courses and up-dates including manual handling, first aid and medication training. There is a detailed induction programme and this was viewed for the most recent staff member. Induction included protection of vulnerable adults and children, learning disability awareness and care planning. There is currently no refresher training for the protection of vulnerable children and adults and this is a Recommendation already discussed earlier in this report. Supervision records were sampled and staff members receive formal and documented supervision from the manager on a monthly basis. Staff have an annual appraisal which is also carried out by the manager. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 24 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 and 42 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Beechwood is a well-managed home with good quality assurance systems in place. The health and safety of residents and staff are promoted and protected. EVIDENCE: The new manger is competent and experienced to carry out this role; she is just finishing an NVQ4 in care and will be starting the RMA qualification next month. She is expecting to complete this by Christmas. She has an HND in Learning Disabilities and Health Studies, and a Certificate in First Line Management. She was the assistant manager in the previous home where she worked before moving to Robinia. The manager is responsible for the day to Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 25 day management of the home including managing the home’s budget for staff, food, and maintenance. There are good arrangements in place for quality assurance at this home and for gaining resident’s and relative’s feedback. There is a service development plan which was developed by the manager following a quality audit of the home. There is a quality assurance manager at Robinia who oversees this process. There are Regulation 26 visits to the home, as well as resident’s meetings and reviews. Each resident’s care plan has goals and achievements clearly noted. There is a Resident’s Forum which is for residents who live on this site as well as annual questionnaires for them to complete with support. Staff also have input through staff meetings and supervision. Policies and procedures are regularly reviewed and the manager has started converting many of these into more resident friendly formats to enable those who live at the home to be feel more included. There are arrangements in place to promote health and safety including a maintenance team who carry out repairs and maintenance. They also make adaptations for example making special cabinets to hold resident’s televisions and music players. There is a weekly health and safety ‘walkthrough’ by a senior member of staff checking for any hazards. There is a health and safety policy in place and a legionella risk assessment on file, together with an annual legionella test. A number of documents were sampled including the electrical appliance testing certificate (February 07); the Gas Safety Certificate (January 07); and the fire risk assessment (February 07). The home was displaying a current insurance certificate and their CSCI certificate of registration. Though there was a legionella risk assessment in place, the templates where the completed checks would be noted were blank. It was not clear if all the recommended checks were being carried out and monitored and the manger said she would confirm this with the maintenance department. The company carry out health and safety audits and produce a report but the one for this home has not been done since May 2005. In addition there was no evidence of a visit by the environmental health department of the local council and the manager was asked to follow this up, and in particular to highlight the freezer which is currently in the laundry room. The manager was asked to review the security arrangements for the hazardous substances cupboard and she reported to CSCI that a more suitable locking device had been fitted the next day. Beechwood DS0000013702.V339296.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 X 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 27 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. Standard 1. YA20 Regulation 13(2) Requirement More detailed guidance for staff must be available on ‘as required’ medication, to ensure all staff are administering this in a consistent way. The health and safety issues highlighted in the final paragraph of this report must be reviewed including: arranging an up-todate health and safety audit by the organisation; checking there are suitable monitoring arrangements to prevent legionella; and contacting the environmental health department of the local council regarding a visit from them. Timescale for action 25/07/07 2. YA42 13(4)(a) (b)(c) 25/07/07 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. 2. Refer to Standard YA12 YA23 Good Practice Recommendations Educational history and attainments should be included in one resident’s care plan as discussed with the manager. The policy to have only one training session for staff on safeguarding vulnerable children and adults should be reviewed. Refresher training should be considered to ensure recent developments in this area are brought to the DS0000013702.V339296.R01.S.doc Version 5.2 Page 28 Beechwood attention of staff, e.g. The Mental Capacity Act. Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office Burgner House 4630 Kingsgate Oxford Business Park South Cowley, Oxford OX4 2SU 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. Extracts may not be used or reproduced without the express permission of CSCI Beechwood DS0000013702.V339296.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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