Inspection on 30/01/07 for Beechwood Residential Home

This inspection was carried out on 30th 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beechwood Residential Home 03/01/06

Beechwood Residential Home 08/08/05

Beechwood Residential Home 14/01/05

Beechwood Residential Home 09/08/04

Similar services:

Ashlong House

Norbury Crescent (30)

Edenvale

Wadham Avenue

Chatsworth Care - Dawson House

Cowden Road, 52 - 54

Chatsworth Care - Tudor Lodge

Foxley Lane (121a)

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

CARE HOME ADULTS 18-65 Beechwood Residential Home Beechwood Residential Home 17 Ismalia Road Forest Gate London E7 9PH Lead Inspector Sharon Lewis Unannounced Inspection 30th January 2007 10:20 Beechwood Residential Home DS0000022830.V326175.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 Residential Home DS0000022830.V326175.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 Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beechwood Residential Home Address Beechwood Residential Home 17 Ismalia Road Forest Gate London E7 9PH 020 8472 2771 020 8472 2771 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) Mrs Pretim Singh Mr Benjamin Arthur Piper Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd January 2006 Brief Description of the Service: Beechwood Residential Home provides accommodation and care for six adults with learning disabilities. A private individual Mrs Pretim Singh owns the home. Service users benefit from residing in a warm, family atmosphere where 24hour care is provided. The home has four single rooms and one shared double room. All bedrooms are located upstairs. The home does not have a passenger lift; therefore it is unsuitable for service users with mobility needs. Service users have access to two lounges, which includes a dining area and a rear patio garden with garden furniture. Local amenities include a culturally diverse parade of local shops, post office and food outlets in Upton Lane. Several bus routes serve the home. The nearest underground station is Upton Park, on the District Line. The nearest British Rail station is Forest Gate. Currently the home is full and there are no placement vacancies. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Unannounced Inspection was commenced on a Tuesday morning and lasted approximately seven hours. A colleague within the Communications Directorate shadowed this Inspection. The overall objective of this Inspection is to ensure service users are receiving the best possible care and their welfare is safeguarded and promoted at the care home. In addition to checking the home’s compliance with the legal requirements made at the last Inspection. The Inspector spoke to all service users currently living at the home. Individual discussions were also held with the two Support Workers on duty and the Registered Manager. Service users daily logs, medication and medication administration records, fire safety records and other relevant documentation were examined. Service users also assisted in the tour of the premises. The Inspector would like to thank all service users and staff members for their assistance with this Inspection. What the service does well: Beechwood Residential Home continues to promote a homely, family orientated atmosphere for service users from various culture backgrounds and age ranges. All service users related they were happy living at the home and had good social skills. Service users have a good quality of life and are able to take part in age, peer and culturally appropriate activities. The home demonstrated that service users are attending relevant day centre facilities, college and social clubs. Independent living skills are encouraged and service users undertake various household chores. This includes shopping, cooking, emptying and loading the dishwasher, setting and clearing the dining table and emptying the bins. Service users engage in their local community by going shopping, to the bank, cinema, to the pub, local theatre, eating out, swimming and accessing local amenities. Service users enjoy a varied social life, attending the Bubble club, and other social events. Discussions and photographs evidenced that service users enjoy their annual holidays. Last year service users enjoyed a holiday to the Isle of Wight. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 6 Service users benefit from a committed and caring Manager and a competent and stable staff team. Choice, independence and dignity are actively promoted. Observation and documentation evidenced positive staff interactions. Staff had built good relationships with service users and understood their individual needs. What has improved since the last inspection? What they could do better: During this Inspection six legal requirements were highlighted and four recommendations. The Statement of Purpose and Service User Guide must be updated to reflect the changes in registered numbers. Prospective service users must have access to up-to-date information, to enable them to decide if they wish to live in the home. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 7 Service users must live in a well-maintained environment. The home must ensure lace curtains are appropriately cleaned or replaced. The identified chair in the lounge must be recovered or replaced. Service users must benefit from the home’s management practices. Staff must ensure financial records are accurately maintained. The home must ensure all staff receive regular recorded supervision. The proprietor must ensure monthly visits are undertaken in accordance with Regulation 26. The homes business plan and financial plan must be forwarded to the Commission for Social Care Inspection. 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 Residential Home DS0000022830.V326175.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 Residential Home DS0000022830.V326175.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): 1-4 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beechwood Residential Home has the necessary documentation and demonstrated the ability to meet service users individual needs. The Statement of Purpose and Service User Guide however must be kept up-todate. EVIDENCE: Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 10 Beechwood Residential Home understands the significance of having sufficient information when choosing a new home. The home has produced a Statement of Purpose and Service User’s Guide. The Statement of Purpose describes the home aims to “ provide a secure and happy environment; taking into account individual needs of service users and will provide 24-hour holistic support.” The only issue highlighted was the need for the Statement of Purpose to be updated to reflect the service changes. The home is now registered to provide six beds. The Service User Guide includes service users comments on what they like about living at the home. The Service User Guide must also be updated to reflect the changes in registered numbers. Prospective service users must have access to up-to-date information, to enable them to decide if they wish to live in the home. Admissions to the home only take place if the service is confident staff have the skills, ability and qualifications to meet the assessed needs of the prospective service user. Since the last Inspection one new service user has moved into the home. The home evidenced transition planning, which focused on the new admission. Evidence was seen that this service user had visited the home prior to moving in. Having a chance to meet with staff and the other service users they would be sharing their home with. This service user although non-verbal indicated he was happy living at the home. Being comfortable in his surroundings and interacting amiably with other service users and staff. They were also photographic evidence of the new service user enjoying a holiday with his housemates. Beechwood Residential Home has a referral and admission policy and eligibility criteria. The home is able to provide short-term care for an agreed period of one to six months. The home is unable to meet the needs of service users with great mobility needs, severe challenging, aggressive or violent behaviour or uncontrollable double incontinence. Evidence was seen that the home is able to meet the assessed needs of the service users. This included meeting the needs of service users from diverse cultural groups and varying learning disabilities. Where service users needs or preferences have changed, the home evidenced strong partnership working with Health and Social Services. One service user proudly informed the Inspector that they were looking forward to moving into more independent accommodation. Beechwood Residential Home DS0000022830.V326175.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 - 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users individual needs and choices are promoted at Beechwood Residential Home. EVIDENCE: Four service user files were examined during this Inspection. Service users care plans reflected their assessed and changing needs. The care plan is regarded as a working tool and staff evidenced that they are focused on assisting service users lead an independent lifestyle, which meets personal goals, needs and enhances their quality of life. The home evidenced that care plans were regularly reviewed. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 12 All service users have allocated key workers. These are assigned staff members who co-ordinate a service user’s care plan and monitors their progress. Staff demonstrated that assistance and support was given to service users to make decisions about their own lives. Examination of the home’s daily logs, and service users’ plans, evidenced that service users exercised choice in their daily lives. Service users meetings give them the opportunity to meet as a group and have an impact on decision making within the running of the home. Records evidenced that monthly meetings were held. Topics discussed included activities, menu planning, holidays and the new service user. It is recommended that the person who records the minutes, prints their name to ensure accountability. Service users are supported to take risks as part of an independent lifestyle. All service users have current risk assessments. If necessary risk assessments are supported by appropriate guidelines to manage individual behaviours. The home has a confidentiality policy. Service users’ files were securely stored in the Manager’s office. Beechwood Residential Home DS0000022830.V326175.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): 11 - 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users lifestyle needs are individually promoted at Beechwood Residential Home. EVIDENCE: Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 14 Beechwood Residential Home demonstrated a commitment to the promotion of the individual’s right to live an ordinary and meaningful life, both in the home and in the community appropriate to their peer group, and to enjoy all the rights and responsibilities of citizenship. Service users’ files, observation and discussions with staff evidenced the opportunities service users have to fulfil their spiritual needs. In addition to having opportunities for self-advocacy, independent skills and therapeutic interventions. Service users attend church on Sundays, attend a women’s group, men’s group, music and drama therapy. Their rights are additionally promoted through advocacy involvement. Communication was seen to be maximised through the use of Makaton and communication tools. Service users are involved in meaningful daytime activities of their own choice and according to their individual interests and capability. Service users are able to take part in age, peer and culturally appropriate activities. Individual pictorial activity programmes are displayed in the dining area. Service users attend various day centres, colleges and social clubs. Evidence was seen of service users developing various skills at their day services. An example being service users had made a range of high quality pottery items. Discussion with service users, staff and documentation evidenced that service users maintain family and personal relationships. This included telephone contact, visits to their respective families, visits by family and friends to the home. During the Inspection a service user was observed phoning people on their mobile phone. Birthdays and special occasions are celebrated with parties. Service users have developed friendships with the service users who live in the other home owned by the proprietor. Routines are very flexible and residents can make choices in major areas of their life. During the Inspection service users were observed listening to music, playing Scrabble and watching television. Independent living skills are encouraged and service users undertake various household chores. Each service users daily living responsibilities are detailed in their weekly programme. These include shopping, cooking, emptying and loading the dishwasher, setting and clearing the dining table and emptying the bins. Service users engage in their local community by going shopping, to the bank, cinema, to the pub, local theatre, eating out, swimming and accessing local amenities. Service users enjoy a varied social life, attending the Bubble club, parties, and other social events. Service users enjoy their annual holidays. Last year service users enjoyed a holiday to the Isle of Wight. Menus were examined and found to be nutritious, balanced and reflected a range of cultures. Service users enjoy traditional White British, African and Italian meals. Fruit is readily available in the kitchen. Service users individual choices are incorporated in the pictorial weekly menu. Service users are able Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 15 to practically assist in the food shopping trips, to the supermarket. Food supplies and storage was examined. The home has ample supplies of food and good food hygiene practices are maintained. Beechwood Residential Home DS0000022830.V326175.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 – 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users personal and health needs are promoted at Beechwood Residential Home. EVIDENCE: Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 17 Beechwood Residential Home understands the key principles of giving personal support and are responsive to each service users varied and individual needs. Service users receive personal support in the way they prefer and require. Times for getting up/going to bed, baths, meals and other activities are flexible and dependent on service users needs and preferences. Service users choose their own clothes and their overall appearance reflects their age and individual personality. Female service users had manicured nails and all service users were dressed in a modern fashion. Service users are encouraged to pursue a healthy lifestyle and weight is monitored. The home has it’s own exercise bike, which is located in the dining area. Service users are encouraged follow a healthy diet and undertake regular exercise. Service users have access to health care services that meet their assessed needs both within the home and in the local community. All service users are registered with a doctor and had received a ‘flu jab’. Service users are supported to access NHS healthcare facilities in the locality. These include the dentist, optician, chiropodist, speech and language therapy, psychology and specialist health services. Evidence was seen that the home made efforts to locate health professionals, who had experience of working with people who have a learning disability. An example seen was a dentist who specialises in this area. Documentation evidenced that service users health is monitored and potential complications and problems are identified and dealt with at an early stage, including prompt referral to an appropriate specialist. The home evidenced their ability to responsibly assist in managing diabetes. Staff assist with escorting service users on health appointments. Guidelines are in place to manage specific health issues. The home has developed a comprehensive medication folder with various policies, including medication administration, security and disposal of medication. Medication is stored in a locked cabinet, which is stored in the staff office. Each service user has a medication profile that includes their photograph, medication details and allergies. Medication records were examined and were found to be accurately maintained. The first aid box is located in the kitchen and was found to be adequately stocked. Beechwood Residential Home DS0000022830.V326175.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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beechwood Residential Home endeavours to minimise risk and safeguard service users from abuse or harm. EVIDENCE: The home has produced a complaints policy and procedure and the Service Users Guide includes complaints information. There have been no service user complaints since the 2001. The home has an open culture, discussions and documentation evidenced that service users knew they could approach the management, if there was anything they were not happy with. Adult Protection, Whistle blowing and Restraint policies and procedures have been produced. Discussions with staff evidenced a better awareness of safeguarding the wellbeing of adults. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 19 Service users financial records were examined and were found to be accurately maintained. Service users spent their monies on activities and purchasing items and services, which enhanced their lifestyles. This included attending parties, social outings, barber/hairdresser and purchasing flowers for their mother. One discrepancy was found in a financial record, where the wrong date was written. Staff must ensure financial records are accurately maintained. Beechwood Residential Home DS0000022830.V326175.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, 25, 26, 27, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beechwood Residential Home provides service users with a homely environment. Minor furnishing issues must be further addressed. EVIDENCE: Beechwood Residential home is located in a residential street in Forest Gate, in the London Borough of Newham. The premises is a terraced property which blends easily into the neighbourhood and presents as a family home. The home is comfortable, clean and free from offensive odours with sufficient and suitable heating and ventilation. This home is unsuitable for prospective service users with mobility needs. All bedrooms are on the first floor and second floor and a passenger lift is not available. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 21 Local amenities include a parade of local shops, post office and food outlets in Upton Lane. The home is in close proximity to the Green Street shopping area and Woodgrange Road, which has a range of culturally diverse shops, services and amenities. Stratford, Ilford and East Ham shopping areas are also easily accessible by public transport. Several bus routes serve the home. The nearest underground station is Upton Park, on the District Line. The nearest British Rail station is Forest Gate. The home has four single bedrooms and one shared bedroom. All bedrooms were inspected. Bedrooms were lockable with sufficient space for personal items. Service users can bring their own furniture and can decorate and personalise their rooms subject to fire and safety requirements. Service users’ bedrooms contained televisions, compact disc players, computers, family photographs, pictures, ornaments, collectible items, items made by service users and certificates of achievement. The bedroom of the new service user was found to have no items on display, which reflected them. The bedroom of the recently admitted service user should reflect his personality, heritage and interests. Service users have access to two lounges. The front communal lounge is comfortable and homely. Leather settees promote a contemporary atmosphere. Service users have access to a large television, a video and a music system. The rear lounge includes a dining area, comfortable seating and an exercise bike. Service users have their own notice board, which includes information in pictorial formats and Makaton signs. A utility room with laundry facilities adjoins the dining lounge. There is a choice of two bathrooms, one with shower facilities and the other having a deep bath. Bathrooms were attractively tiled and facilities were of a high standard. Service users have their own telephone, which is located in the ground floor hallway. Service users additionally benefit from a well-maintained patio garden with flowers and garden furniture. Service users must reside in a well-maintained homely environment. The following maintenance issues must be addressed. The lace curtains in some of the bedrooms looked ‘drab’ and ‘off colour’. The home must ensure lace curtains are appropriately cleaned or replaced. A chair in the lounge was in disrepair. The seating must be recovered or replaced. Beechwood Residential Home DS0000022830.V326175.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): 31 - 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Beechwood Residential Home has sufficient staffing and service users benefit from an effective staff team. Further improvements however are needed in supervision practices. EVIDENCE: Staff evidenced that they knew and supported the main aims and values of the home. This included their ways of working, respective roles and responsibilities. Staff demonstrated an awareness of service users’ individual needs. Service users additionally evidenced staff’s ability to meet individual needs. Service users were observed interacting amiably with staff. Staff interacted in an equally, good-natured manner. Staff interviewed expressed their enjoyment in working at the home, stating it was “great working here”. Staff felt the home is “running smoothly”, “residents are happy” and felt they worked well as a team. A new staff training programme is currently being finalised. The home has demonstrated a commitment to National Vocational Qualification (NVQ) Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 23 training. The majority of staff have obtained their NVQ qualification. The Registered Manager and Support Workers confirmed that staff receive training that focuses on topics relevant to the service user group. Service users benefit from a relatively stable staff group. Since the last Inspection a new part-time member of staff has been employed. Examination of the staffing rota and observations evidenced that the home was sufficiently staffed to meet the individual and collective needs of service users. Staffing rotas evidenced that at least one member of staff is on duty. An on-call system is in operation in the event of an emergency. Agency staff are not used and shifts are covered through over-time by the permanent staff team. Staff related that they received supervision and felt adequately supported. Supervision records were examined and evidenced that service users needs and staff’s individual development were discussed. The only issue highlighted was for all staff to have regular supervision. Staff should have supervision at least six times a year. The home must ensure all staff receive regular recorded supervision. Beechwood Residential Home DS0000022830.V326175.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, 38, 39, 41, 42 & 43 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is effectively managed more consistent, formalised monitoring however is needed. EVIDENCE: A private individual Mrs Pretim Singh owns Beechwood Residential Home. The Registered Provider is a qualified social worker. She owns and is the Registered Manager of another home for people with learning disabilities. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 25 The Registered Manager has five years social care experience and holds relevant management qualifications. In addition to degrees and experience in the psychology field. The Registered Manager is currently undertaking a Doctorate in Psychology. The Registered Manager was observed to have a good relationship with service users and staff. He was described as being “very good” and “great”. The home provides an open, positive and inclusive atmosphere. An Equal Opportunities policy is in place. All service users stated that they were happy and enjoyed living in the home. Staff felt service users were given “good freedom of choice.” Staff stated they had regular staff meetings and were kept informed of developments within the service. Staff interviewed related they feel valued, are able to voice their opinions, concerns and are able to use their initiative. The home has a quality assurance system that includes formal feedback from service users, relatives and health and social care professionals. Evidence was seen of questionnaires received from all parties, which indicated their satisfaction with the home. T The proprietor visits the home on a regular basis and carries out monthly monitoring visits. Examination of these records evidenced gaps where visits were not undertaken consistently every month. The proprietor must ensure monthly visits are undertaken in accordance with Regulation 26. The home’s business and financial plan was not available. The homes business plan and financial plan must be forwarded to the Commission for Social Care Inspection. Service users daily logs were examined. Records were found to be up-to-date and focused on meaningful information which details service users outcomes. The only issue was in relation to correction fluid being used. To promote accountable and transparent communication staff should ensure correction fluid is not used on service users records. Health and safety records were examined and were up-to-date. The home has current health and safety certificates. The home has the necessary insurance cover in place to enable it to fulfil any loss or legal liabilities. Accidents and incident records are appropriately maintained. The home have produced a risk assessment, which includes fire and other general risks to staff and service users. It is recommended that the person who reviews the risk assessment prints their name, for accountability. Fridge and freezer temperatures are recorded on a daily basis; weekly fire alarm tests and regular fire drills were undertaken. The names of all service users involved in each fire drill is usually recorded. This was however not consistent practice. This matter was discussed with the Registered Manager who was able to identify the service users involved. Staff should consistently record all service users involved in each fire drill. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 26 The home has developed a service development plan, which focuses on better service user outcomes. Topics included increasing the range of activities, improving staffing, evaluating systems, promoting a healthy lifestyle and person centered planning. Evidence was seen that the majority of objectives had been successfully met. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 27 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 2 2 3 3 3 4 3 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 2 25 3 26 3 27 3 28 3 29 3 30 X STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 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 3 2 X 3 3 2 Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 28 Are there any outstanding requirements from the last inspection? No 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 YA1 Regulation 4&5 Requirement The Statement of Purpose and Service User Guide must also be updated to reflect the changes in registered numbers. Staff must ensure financial records are accurately maintained. The home must ensure lace curtains are appropriately cleaned or replaced. The identified chair in the lounge must be recovered or replaced. The home must ensure all staff receive regular recorded supervision. The proprietor must ensure monthly visits are undertaken in accordance with Regulation 26. The homes business plan and financial plan must be forwarded to the Commission for Social Care Inspection. Timescale for action 01/04/07 2. 3. YA23 YA24 17 (2) 16 (2) (c) 01/03/07 01/06/07 4. 5. 6. YA36 YA39 YA43 18 (2) 26 25 (2) & (3) 01/03/07 01/03/07 01/04/07 Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 29 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. 4. Refer to Standard YA8 YA26 YA41 YA43 Good Practice Recommendations It is recommended that the person who records the service user meeting minutes, prints their name to ensure accountability. The bedroom of the recently admitted service user should reflect his personality, heritage and interests. Staff should ensure correction fluid is not used on service users records. It is recommended that the person who reviews the risk assessment prints their name, for accountability. Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection East London Area Office Ferguson House 113 Cranbrook Road Ilford London 1G1 4PU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beechwood Residential Home DS0000022830.V326175.R01.S.doc Version 5.2 Page 31 - 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. 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