Inspection on 05/12/05 for Beechwood House

This inspection was carried out on 5th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechwood House 29/01/07

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 Susan Richards Unannounced Inspection 5th December 2005 10:00 Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 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.V271404.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 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.V271404.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of this inspection was on the case tracking of an identified service user, the overall organisation of and approaches to care delivery and service users experiences of this. What the service does well: What has improved since the last inspection? What they could do better: Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 6 Review the admissions criteria and provide clear policy guidance regarding the formulation, recording and review of individual risk assessments and care planning information by the home for any service user who may be admitted there. Where any service user has entered the home for a period of rehabilitation and therapeutic support/education, they are provided with clear information about the purpose, duration and requirements of the programme. And their care plans reflect this as agreed with them. Ensure that when ‘as required’ (prn) medication is prescribed for a service user in relation to their behaviours, that there is a written plan, which clearly identifies the circumstances under which this is to be administered and specifies the actual dose in accordance with these. 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. Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 & 5 Overall service users accommodated were informed and involved in their care. However, for one service user with complex needs, who had no assessment and care planning information as formulated by the home (and as properly agreed with that service user) the ability of the home to delivery a clear and consistent approach to their care and personal support was potentially compromised. EVIDENCE: The arrangements for the recent admission of a service user case tracked were examined. The Inspector was unable to speak with the service user who was not available at the time of the inspection. However, there were clear records of visits to the home and consultations with the service user about their decision to live there. The views of significant others, including health and social care professionals were also well accounted by way of comprehensive pre-admission needs assessment information, formulated by them. This included the rehabilitation and therapeutic needs assessment information as provided by state registered healthcare professionals. However, this information had not been collated and recorded by the home as a full needs assessment and care plans had not been formulated by the home and with the service user, based on the above. The reason for their admission was discussed with the manager and staff and information provided for that service user was examined (service user guide and terms and conditions). Given the, rehabilitation and therapeutic needs of Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 9 the service user, they (the service user) had not been provided with clear information about the purposes, duration and requirements of this programme. There was some information recorded in respect of potential restrictions on the individual’s freedoms by way of a written contract signed by the service user. However, discussions with the manager and staff and examination of preadmission risk assessment information indicated that there was potential for inconsistency of approach, given that there was no full needs assessment (including that relating to risk) or care plans in place as formulated by the home for and with that service user. This was discussed in depth with the manager during the inspection and she advised that these would be provided in accordance with the home’s statement of purpose (range of needs), which was also examined during the inspection. The Inspector spoke with a group of service users about the care and services they received, including ways in which staff assisted them in terms of their daily living arrangements and personal care and support needs. Feedback was very positive and consistent. Service users felt that staff supported them well. The Inspector sampled written terms and conditions/contractual information as provided for individual service users and these were in accordance with requirements. Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, & 9 With the exception of one service user case tracked, service users needs and personal goals were well accounted for and there were suitable methods established to ensure that service users were effectively consulted about their care and home life. EVIDENCE: The comments made under Section One of this report (Choice of Home) in relation to service users care plans, restrictions on individual freedoms and rehabilitation and therapeutic needs and care planning apply here also. For the service user case tracked (as referred to in that section), care plans were those formulated whilst the service user was an inpatient in hospital, prior to their admission to the home and as such were not specific to the care home setting or up to date. The Inspector spoke with a group of service users about their daily lives and about how they made choices in respect of these. Service users spoke enthusiastically and gave many examples of choices and decisions they made, both in terms of their own lives and in conjunction with each other as a group in respect of their daily living arrangements. Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 11 There is a missing persons procedure in place for the home, which was examined. Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Although the standards in this section were not wholly assessed on this occasion, the Inspector examined the medicines records for one of the service users case tracked. Their administration record (MAR) sheet and care records detailed a variable dosage for one of their medicines, which was prescribed to be given ‘as required’ in accordance with their behavioural needs. However, there was no written care plan in place in relation to this. Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 There were satisfactory systems and arrangements in place to enable service users or their representatives to raise concerns or to complain and also to promote the protection of service users. EVIDENCE: The complaints procedure for the home is displayed. Information regarding how to complain is also included in the service user guide provided for each service user and also in a format suitable for service users. Service users spoken with knew how to complain and staff spoken with were familiar with the complaints policy and their responsibilities in respect of complaints made. Records were also examined. There had been no complaints since the previous inspection for this service. There was a system for the separate recording of individuals concerns and suggestions within their own care records. There was recognised policy and procedural guidance in place in relation to adult protection, the prevention of abuse and responding to and dealing with violence and aggression. The arrangements for staff training in respect of these were discussed and were satisfactory. Staff spoken with was conversant with their responsibilities in relation to these. Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: The Manager discussed the format of a revised induction programme to be introduced for all staff in the home. The Inspector will assess this more fully at the next inspection for this service, following its introduction. Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): The standards in this section were not assessed on this occasion. EVIDENCE: Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 2 2 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beechwood House Score X X X X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000019935.V271404.R01.S.doc Version 5.0 Page 19 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 YA2 Regulation 14 Requirement Timescale for action 05/01/06 2 YA3 14 3 YA6 15, 13 4 YA6 13, 15 The registered person must ensure that there is comprehensive needs assessment information for the service user identified, recorded by the home, which is kept under review and revised at any time when it is necessary to do so. The registered person shall 05/01/06 provide written information to the (identified) service user, which indicates that the home is suitable for the purpose of meeting their needs and which provides clear information about the purpose, duration and requirements of their programme Written care plans must be 05/01/06 formulated by the home (for the identified service user and with their involvement), which are kept under review and revised as necessary and which are formulated in accordance with their risk assessed needs. Where an ‘as required’ and 05/12/06 variable dose of a medicine is prescribed for a service user DS0000019935.V271404.R01.S.doc Version 5.0 Beechwood House Page 20 (particularly in respect of their behaviour) a written care plan must be provided, which clearly identified the circumstances under which this is to be administered and specifies the actual dose in accordance with these. 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 YA14 YA2 Good Practice Recommendations The registered persons should continue to review with service users the need for the provision of a computer in the home for their use. The home should ensure that there is clear policy guidance in place in relation to the formulation of comprehensive needs assessment and care planning information by the home for any service user. Beechwood House DS0000019935.V271404.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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