Inspection on 15/11/05 for Beeton Grange

This inspection was carried out on 15th November 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beeton Grange 08/01/08

Beeton Grange 28/02/07

Similar services:

The Lodge Nursing Home

Bracken House

Sunnycroft

Field Farm House

Edgeview Nursing Home

Church Terrace Nursing & Residential Home

The Forbury

The Maples

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

CARE HOME ADULTS 18-65 Beeton Grange 50-55 Beeton Grange Winson Green Birmingham West Midlands B18 4QD Lead Inspector Kath Strong Unannounced Inspection 15th November 2005 11:20 Beeton Grange DS0000064739.V266591.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 Beeton Grange DS0000064739.V266591.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. Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beeton Grange Address 50-55 Beeton Grange Winson Green Birmingham West Midlands B18 4QD 0121 554 5559 0121 523 6362 beeton.grange@carepartnerships.com 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) West Regent Ltd Ms Marlene Myers Care Home 24 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (24) of places Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the home can care for twenty four (24) service users under 65 years of age who are in need of care for reasons of mental health disorder. Accommodation is to be provided in two adjacent units. That two named persons over 65 years of age at the time of admission can continue to be accommodated and cared for in this Home. The home must demonstrate through comprehensive care planning and regular reviews carried out by social services that it is able to meet all the needs of each individual. 01/06/05 2. Date of last inspection Brief Description of the Service: Beeton Grange is a large building situated in Winson Green close to the number 11 bus route for link to the city centre. The home comprises of two individual sections, which are interlinked and are registered as one organisation. The stated function and purpose of the home is to provide care and support to 24 African, Caribbean or Asian people who are recovering from mental health illness. The programmes of care include encouragement and support in promoting residents independence. Assistance is provided with personal budgeting, shopping, cooking, laundry and the development of individual programmes for each resident. The aim of the home is where possible to rehabilitate residents and return them to the community. Accommodation constitutes 22 single bedrooms and two flatlets. Each section has a lounge, dining room and a well equipped large kitchen. There are toilets and bathing facilities strategically located. There are no off road parking facilities. Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to conduct an unannounced inspection, the outcome of which was determined by a number of means. In depth discussions were held with the registered manager and a brief talk took place with a visiting social worker. The acting deputy manager participated with the review of the medications procedure and talked about his role within the home. He also facilitated a tour of the premises and individual discussions held with three residents. Relevant documentation was examined as well as two care plans, one of which included case tracking in order to ensure that all identified needs were being met. At the conclusion verbal feedback was provided and clarification in respect of the adult protection policy supplied to the homes administrator. The inspection focussed upon the key standards not assessed and the three requirements generated at the last inspection and others determined to be appropriate. In order to obtain a full overview of the services provided it is recommended that this report should be read in conjunction with the report from the inspection of 1st June 2005. What the service does well: What has improved since the last inspection? Operatives were present in the home carrying out improvements from the outcome of the fire inspection on the premises. Two bedroom doors were being fitted with automatic closures. Three bedrooms and one flatlet have been redecorated. Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 6 The registered manager and a further eight members of staff are undertaking computer training. 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. Beeton Grange DS0000064739.V266591.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 Beeton Grange DS0000064739.V266591.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): None EVIDENCE: Standards 1, 2, 3, 4 and 5 were examined and fully met at the last inspection. Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Health needs of residents are well met; external professionals provide an integral element of the care. Residents are consulted and encouraged in making decisions about their activities of daily living. Risk assessments need to be specific to the activity in order to minimise risks. EVIDENCE: Care plans are comprehensive; they include mental health and physical problems. During the last inspection the registered manager was reminded to ensure that risk assessments were in place for all internal and external activities. It was determined that no progress has been made in this respect and that the risk assessment tool is too generic as a tool to use for specific problems. A resident was found to be at risk of falls but had not been adequately risk assessed. There was evidence of strong professional relationships and a proactive approach to the involvement of external professionals of varying specialties. Staff encourage and actively support all residents in maintaining full independent living skills by working along side residents. Residents meetings are held regularly, agenda items include all Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 10 aspects of the day to day operations of the home as well as resident’s independence, meals and activities. Residents spoken with reported, “Very nice home, staff very caring, food is very nice”, “Everything alright, food is good”. Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13 and 15 Appropriate leisure activies are encouraged. Residents are supported in maintaining normal lifestyles and personal relationships. EVIDENCE: A resident said that he had recently requested to attend a nightclub. Arrangements were made and he was escorted to a nightclub of choice. Regardless of whether residents have family and friends to provide advice and support all residents following admission to the home are assigned an advocate to act on their behalf. Standards 11, 12, 13, 14, 15, 16 and 17 were examined at the last inspection and found to be fully met. Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 12 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): 20 The medication is well managed promoting good health and ensuring safety. EVIDENCE: Residents are encouraged to take responsibility for their medications by reporting at the designated time to the office. Two staff work side by side in order to ensure a safe system and that the medications are appropriately consumed. The acting deputy manager carries out regular audits and spot checks during times of administration. Since the last inspection the homes written procedure has been further developed and was found to be satisfactory. Standards 18 and 21 were examined at the last inspection and found to be fully met. Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 13 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 and 23 The complaints procedure is comprehensive and resident’s views are listened to and acted upon. The written policy for the protection of residents from the risk of abuse continues to be inadequate. EVIDENCE: The written complaints procedure and the arrangements for investigating of complaints were determined to be satisfactory at the previous inspection. The registered manager advised that the home has not received any formal complaints since the last inspection. The written policy regarding adult protection remains inadequate, in that it requires further development and amendments. The requirement from the previous inspection will be carried forward. All staff have received appropriate training in this aspect of care. Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 14 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): 24, 25, 26, 27, 28, 30 The style, layout and décor of the home is appropriate for the client group and provides a safe environment. EVIDENCE: The premises offer suitable accommodation. Some residents are free to go out unaccompanied and others require supervision. The home is situated within easy access of local amenities and public transport. The home is split into two units, one housing residents with lower dependency needs. Each unit has a lounge, dining room and fully fitted kitchen. Flatlets consist of a bedroom/lounge with kitchen off. The communal areas are especially in keeping with the culture of the occupants. Furniture, fixtures and fittings are of a good standard. There was evidence of attention to detail and that residents are consulted when redecoration is due. The overall impression was of a homely and relaxed atmosphere. The rear garden includes a number of grassed areas. Communal toilets and bathrooms are strategically located throughout the home. Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 15 All bedrooms are of single status and are very individualised. Rooms include personal possessions, pictures and posters. All rooms have a lockable facility and suited door locks with many residents holding their own key. The home was found to be tidy, warm and hygienic throughout. Beeton Grange DS0000064739.V266591.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): 32, 33, 34 and 35 Staff are supplied in adequate numbers and trained to enable them to meet the complex needs of the current client group. EVIDENCE: Staffing levels complied with the required framework and take into account the specific dependency levels of residents. All prospective staff are supplied with a job description and are invited to visit the home and liaise with staff and residents prior to an interview being carried out. Due to the complex needs of residents this process is considered by the home as an essential element of the recruitment process. Another aspect of recruitment is that one resident carries out an informal interview of prospective candidates and reports his findings to the registered manager. Such procedures are viewed as being good practice. The home operates a rolling programme of staff training that includes all mandatory and refresher courses. Further training is provided to meet the specific needs of residents including mental health training, which is supplied by the Primary Care Trust. Standards 31, 34, 35 and 36 were examined at the last inspection and found to be fully met. Beeton Grange DS0000064739.V266591.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): 37, 38, 40 and 41 Senior staff support the registered manager and there are clear lines of accountability. Written policies and procedures continue to be in need of review. EVIDENCE: The management structure of the home includes a registered manager, an acting deputy manager and a senior carer. Between them they provide an on call system for the home. Tasks are delegated in a professional manner and the acting deputy manager has specific responsibilities within the home. As with the previous inspection it was determined that all written policies and procedures were in need of review. The home needs to address this outstanding requirement. Care plans are securely stored whilst permitting staff access at all times. Beeton Grange DS0000064739.V266591.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 X X X X x Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 X 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beeton Grange Score X X 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 3 X x DS0000064739.V266591.R01.S.doc Version 5.0 Page 19 YES 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 YA9 Regulation 13(4)c Requirement The registered manager must develop and implement risk assessments that are specific to individuals needs. The written policy regarding adult protection must be amended and further developed as outlined within the main body of this report. N.B. This remains outstanding from the previous inspection. The home must provide clear evidence that all written policies and procedures are regularly reviewed. This remains outstanding from the previouis inspection. Advice was given that a person has ben appointed to carry out this task. N.B. This remains outstanding from the previous inspection. Timescale for action 31/12/05 2. YA23 13(6) 31/12/05 3. YA40 Appendix 2 28/02/06 Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 20 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. Extracts may not be used or reproduced without the express permission of CSCI Beeton Grange DS0000064739.V266591.R01.S.doc Version 5.0 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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