Inspection on 29/01/07 for Beechwood House

This inspection was carried out on 29th January 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechwood House 05/12/05

Beechwood House 13/07/05

Beechwood House 18/10/04

Beechwood House 12/05/04

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

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

CARE HOME ADULTS 18-65 Beechwood House Devon Drive Brimington Chesterfield Derbyshire S43 1DX Lead Inspector Nancy Bradley Key Unannounced Inspection 29th January 2007 09:00 Beechwood House DS0000019935.V325385.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 House DS0000019935.V325385.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 House DS0000019935.V325385.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechwood House Address Devon Drive Brimington Chesterfield Derbyshire S43 1DX (01246) 476444 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) Elm Care Limited Ms Alison Jane Colledge Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th December 2005 Brief Description of the Service: Beechwood House is provides personal care and support for up to 10 younger adults with learning disabilities and who may have some challenging behaviours. The home is well maintained and provides all single room accommodation, each having a wash hand basin provided. There are adequate separate bathing and toilet facilities and a communal lounge and dining room. Catering and provided centrally, although service users are able to access the kitchen with staff support in order to prepare drinks and snacks in accordance with the capabilities. There is a separate laundry room, which service users can also access with staff support. A small garden area is provided, with seating and also car parking spaces. The philosophy of the home is one of ‘normalisation’ with the aim of promoting service users independence, choice and opportunities for personal development, with care planned in accordance with their risk assessed needs and personal lifestyle preferences. Service users have regular access to activities - personal, social, recreational and educational- both within and outside the home. The Registered Manager and team of care and hotel services staff, provide twenty-four hour support for the service users accommodated. There are suitable ongoing arrangements for staff training and development. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced key inspection and took place over five hours. The Inspector spoke with the Registered Manager and members of staff on duty. During the site visit the Inspector made a tour of the home and joined service users for lunch. Throughout the visit the Inspector observed how the staff were meeting service users ongoing needs. Records were examined relating to the service users and the running of the home. No family or relatives were present during this visit, although the Inspector had a telephone conversation with a family member who stated they were very satisfied with the care the home was giving to their son. Since the last key inspection there has been no change in the service users living at the home. All service users completed the “ Have Your Say” questionnaire, stating they were quite settled at the home, good activities were provided, they liked the staff and they were listened to. The care staff assisted the service user in completing the form. The fees range from £641.90 per week with additional charges for hairdressing, toiletries, and day trips. What the service does well: What has improved since the last inspection? Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 6 The requirements from the previous inspection have been fully complied with by the time of this inspection. There have been no major service changes. 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. The summary of this inspection report can be made available in other formats on request. Beechwood House DS0000019935.V325385.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 Beechwood House DS0000019935.V325385.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): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Arrangements are in place to ensure that service users’ needs are fully assessed and met prior to admission. This ensures that all potential service users holistic needs are appropriately met. EVIDENCE: The majority of the service users who are admitted to the home have their needs assessed by social workers or through the care management system. The single assessment then forms part of the planned care service users receive. Also the home undertakes their own individual comprehensive needs assessments. This was in accordance with a recognised care model and provides a person centred record of their individual needs, including identified strengths and needs, long-term goals, and evaluation. There was evidence on record to show that care management were reviewing the care needs assessment. Family and carers interests were also recorded. There has been no change in service users living at the home since the last inspection visit. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6,7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a care planning and review system in place, which ensures that service users individual needs are met. EVIDENCE: During the visit care plans of three service users were examined. The care plans have been compiled by the staff on each service user and evidence was seen of care plans being reviewed on a regular basis. All service users casetracked had a comprehensive care plan, which was in accordance with their assessed need and formulated within a risk assessment framework. All care plans were very detailed and comprehensive including services users’ individual lifestyle preferences and choices; the interventions prescribed by outside healthcare professionals were appropriate. Daily records are also maintained on each service user. During the visit care staff were observed discussing with service users choices and arrangements for daily living. It was clear from documentation examined that service users knew about their care plans; they were personalised however the service users, family or Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 10 professionals had not always signed them. One service user has regular access to the Advocacy Service. The home is regularly reviewing service user care plans and these were fully recorded. Detailed risk assessments were in place and these included actions to be taken by staff. Following examination of records, historical and miscellaneous information on service user’s records had been archived. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were arrangements in place to enable service users to maintain and develop appropriate relationships and to participate in activities both in the home and outside in the wider community in accordance with their preferences and wishes. The home provides a well-balanced and nutritious diet to ensure that individual service users requirements are appropriately met. EVIDENCE: During the visit the inspector spoke with service users and care staff about the activities service users were engaged in and the arrangements for these. The care records of all service users provided detailed needs assessment and care planning information regarding their social, recreational, educational and occupational activities both within the home and outside in the community. The service users personal goals, choices and preferences were identified and there were properly recorded risk assessments in place for each service user in relation to the activities they were engaged in. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 12 The home takes service users on holiday each year to the coast and photographs were on display showing how they had spent their time. The holidays are tailored to the individual needs and abilities of the service user. Information on service users’ records indicated that contact with family and friends were appropriate and that were they play an important part in their lives, the home maintains good contact with them. Restrictions in contact were clearly recorded and were with service users agreement. From examination of the menus the home is providing a healthy well-balanced and nutritious diet with some service users on special diets. Service user’s weekly weights are recorded. During the visit the inspector joined the service users for lunch. The service users are given a choice if they do not like the options on the menu. The staff were observed checking with service users as to their likes and dislikes. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18,19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive personal and health care support in a way, which promotes their independence and is in accordance with their preferences and beliefs. EVIDENCE: During the visit it was clear that the service users’ privacy and dignity are respected, and where service users need supervision during personal care this is recorded in their care plan. From records examined and from discussions with staff, service users’ health and personal needs were being met Service users ‘were generally healthy and records showed that staff promptly contacted the appropriated medical services. All service users’ attended services within the community including optician, podiatry, and dentist. The home operates and monitors service users medication. None of the service users are able to administer their own medication. All staff have received training on medication training procedures. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 14 The arrangements for receipt, storage, administration and disposal of medication were also examined and found to be satisfactory. All medication is recorded on MAR sheets. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 15 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are suitable arrangements in place to safeguard service users welfare, which enables their concerns and complaints to be listened to and acted upon EVIDENCE: The home has a complaints procedure, which is included in the service users guide which all service users have a copy of. The complaints procedure is also displayed throughout the home. The home has developed a format which is accessible to service users and they are made aware of how to make a complaint and who they can complain to. Records seen indicated that no complaints had been made about the home since the previous inspection. The Commission for Social Care Inspection has not recvied any concerns about this home. The procedure contains the new complaints address of the Commission for Social Care Inspection and informs the complainants that they are able to contact the Commission at any stage of the complaints process if they wish to do so. The Registered Manager has changed the practice for recording complaints; this now gives a clear auditable trail for recording complaints and concerns. The system allows for: • Numbered pages so they cannot be removed. • The Registered Person now signs and dates the complaints record. • Details of the complaint, the investigation and outcomes are recorded. The home has good links with the Derbyshire Advocacy Service, and they support the service users in making complaints should they wish to do so. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 16 From discussions with the care staff and from records examined there has been no reported incidents or allegations under the safeguarding of adults procedure since the last inspection. The staff confirmed they had received training on safeguarding of adults. As discussed with the Registered Manager the policy and procedure for adult protection needs to be update to reflect the change of focus to the Safeguarding of Adults. As a sign of good practice the information file on Adult Protection should also be updated and to include local Safeguarding procedures. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 17 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users in live in a safe and well-maintained home, which suits their needs and promotes their independence, privacy and lifestyle. EVIDENCE: The Inspector carried out a full tour of the home, accompanied by the Registered Manager. All communal areas were inspected together with staff facilities. Service users’ bedrooms were inspected with their agreement and all rooms had been decorated and furnished to their personal choice and all were personalised. The home was clean, well maintained, well furnished, equipped and well lit and heated. There is a central kitchen and separate laundry and staff facilities. As discussed with the Registered Manager the grouting in the bathrooms needs attention. The Registered Manager confirmed that they have an on-going programme of refurbishment and decoration. There is a small garden and patio area with garden furniture, which is used by service user to sit out at various times of the year. Several of the service users help with the garden maintenance. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 18 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): Standards 32,34,35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has robust recruitment procedures and practices in place which ensure the safety and protect the service users. Service users are well supported by an effective staff team who are appropriately trained EVIDENCE: The home operates a key-worker system and the staff spoken with during the visit where aware of the individual needs of the service users. From records examined during the visit over 50 of the staff have attained a National Vocational Qualification at level 2 or above. The home has a recruitment and selection policy in place. Several staff records were examined and generally these were well presented. All staff have a current Criminal Records Bureau check however there was no audit trail on the information obtained from the Criminal Records Bureau. The Criminal Records Bureau number, date of request and reply, level of check and details of what the check was made against all need to be recorded for each staff member. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 19 Copies of staff qualifications were on file. There has been no change in staffing since the pervious inspection. Staff spoken with during the visit stated there were good training and development opportunities. Details of staff training undertaken over the last twelve months together with training planned was provided by way of the pre inspection questionnaire. Records examined and discussions confirmed this. All staff have a Personal development Plan. The home has a staff supervision policy place. There was evidence in staff records to show that staff appraisals were being undertaken and staff had received supervision. However, this did not always meet the requirement of six times per year. The Registered Manager stated that formal supervision had not always taken place, however all staff now had a supervision contract and dates for supervision. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 20 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): Standards 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems are in place to ensure that service users have a voice and their views are listened to. EVIDENCE: The Registered Manager has completed the Registered Manager’s Award, NVQ Level 4 in care and management and has a relevant job description. The home has developed a system for auditing quality and monitoring all services provided by the home. The Registered Manager provided copies of the most resent audits undertaken by the home for the inspector. These confirmed that the necessary service aspects of the home had been audited. The Regulation 26 visits are under taken by the Registered Managers for the homes within the Elm Care Group these were seen and found to be satisfactory. The home currently does not seek views from family, friends or stakeholders about the services it provides. Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 21 A sample of service/maintenance records was examined (including gas and electricity services) and there was confirmation that all the equipment had been properly maintained. Evidence of checks having been carried out was provided to the Commission for Social Care Inspection Systems were in place for the monitoring and maintaining the hot water temperatures. On examination of health and safety records previous inspection certificates needs to be achieved Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 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 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 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 3 X Beechwood House DS0000019935.V325385.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA23 Regulation 13 Requirement The homes policy on adult protection must be revised and updated to reflect current practice. All applicants must comply with the homes policy and procedures on staff recruitment as outlined in Schedule 2 of the National Minimum Standards. All staff must have regular supervision in line with the National Minimum Standard 36.4 Timescale for action 31/03/07 2 YA34 18 31/03/07 3 YA36 19 Schedule 2 31/03/07 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 3 Refer to Standard YA6 YA34 YA42 Good Practice Recommendations Service users or their representatives should sign the care plan. The Registered Person should record the essential details from staffs Criminal Records Bureau checks before they are destroyed. Previous health and safety inspection certificates should be archived. DS0000019935.V325385.R01.S.doc Version 5.2 Page 24 Beechwood House Commission for Social Care Inspection Lincoln Area Office Unity House, The Point Weaver Road Off Whisby Road Lincoln LN6 3QN 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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