Inspection on 08/01/08 for Beeton Grange

This inspection was carried out on 8th January 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beeton Grange 28/02/07

Beeton Grange 15/11/05

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 Brenda O’Neill Key Unannounced Inspection 8th January 2008 09:30 Beeton Grange DS0000064739.V353724.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 Beeton Grange DS0000064739.V353724.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. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 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 8681 beeton.grange@carepartnerships.com the.willows@ashbourne.co.uk West Regent Ltd 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) 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.V353724.R01.S.doc Version 5.2 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. 28th February 2007 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 individuals’ independence. Assistance is provided with personal budgeting, shopping, cooking, laundry and the development of individual programmes for each person. The aim of the home is where possible to rehabilitate the people living there and help them return to community living. Accommodation comprises of 22 single bedrooms and two flat lets. Each section has a lounge and dining room. There are toilets and bathing facilities strategically located. There are no off road parking facilities. The recently updated service user guide details that the fees at the home range from £400.44 to £2059.00 per week. This is dependent on the pre admission assessment and the level of support individuals require. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. One inspector carried out this key inspection over one day in January 2008. During the course of the inspection a tour of the home was undertaken and the care for three of the people living in the home was tracked. The inspector also sampled documentation in relation to care, staff training and recruitment and maintenance in the home. The inspector spoke with the manager and responsible individual of the home, two staff and six of the people living in the home. Prior to the inspection the manager had returned to the commission a completed annual quality assurance assessment (AQAA) which gave some additional information about the home. Questionnaires were sent out to six of the people living in the home, three health care professionals and three relatives. A total of six were returned. All the comments received were positive about the service offered at the home. The home had not had any complaints or adult protection issues raised with them since the last key inspection and none had been lodged with the commission. What the service does well: The home has a stable staff team which is very good for the continuity of care of the people living in the home. The staff are well trained and had good relationships with the people living in the home comments received included: ‘I get on O.K. with staff.’ ‘I like the staff. They generally listen.’ ‘Staff are fine, enough staff around.’ The preadmission assessment process at the home was good ensuring people who wanted to move into the home were consulted and that staff knew their needs prior to admission. People were able to visit the home prior to admission on several occasions if they wished for varying periods of time before they decided if they wanted to live in the home. The personal and healthcare support offered and provided to the people living in the home met their diverse needs. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 6 The people living in the home were assisted within the home to develop and maintain life skills such as budgeting, shopping, domestic skills and cooking. Clearly from the records seen and the activities board a range of activities were available for the people living in the home. These included going out for meals, to the cinema, day centres, visits to the temple or the mosque, college courses and so on. There was ample evidence that the people living in the home had contact with their families on a regular basis wherever possible and staff supported them with this where necessary. The recruitment procedures for new staff were robust and ensured the people living in the home were safeguarded. The home is quick to respond to any issues raised during inspections. This was evidenced by the speed they looked into the concerns raised about medication during this inspection. This ensures the people living in the home are safeguarded. The home provided the people living there with a comfortable, clean and homely environment in which to live which met the group and individual needs. The manager of the home was very experienced and had a good knowledge of the needs of the people living in the home. She ensured the home was run in the best interests of the people living there. What has improved since the last inspection? All the care plans and risk assessments for the people living in the home had been reviewed and updated. These were generally well detailed and indicated how the needs of the people living in the home were to be met and any risks minimised. Risk assessments had been put in place for the people living in the home that were likely to miss health care appointments. The people living in the home had been consulted about these and plans had been put in place to try and ensure appointments were not missed. Staff had received updated training in adult protection issues and other safe working procedures such as food hygiene. This ensured they were able to work safely with the people living in the home. There had been some improvements to the environment since the last inspection including: refurbishment of the shower rooms, some redecoration and purchase of some new furnishings. This further enhanced the comfort and facilities available for the people living in the home. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 7 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. Beeton Grange DS0000064739.V353724.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 Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There was ample information available for people wanting to use the service to help them make an informed decision about whether the home could meet their needs. People wanting to move into the home were fully involved in the assessments process and could visit the home to assess the facilities prior to admission. People were issued with a contract at the point of admission so that they were aware of the terms and conditions of residence at the home. EVIDENCE: The statement of purpose and service users guide for the home had recently been updated. The documents included all the necessary information to help anyone wanting to move into the home to decide if the home could meet their needs, including the fees charged at the home. The files for two people who had been admitted to the home since the last key inspection were sampled. Both files included evidence that the manager of the home had undertaken comprehensive pre admission assessments for the individuals. It was evident that the individuals had been involved in this process as the assessments included several statements made by them. The Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 10 assessments included detail of what care plans and risk assessments would need to be put in place if the individual was admitted to the home. The files also evidenced that individuals could visit the home as often as necessary to assess the facilities available to them. One of the individuals had had several pre admission visits including day visits, over night stays and a weekend stay. Both files included copies of contracts that had been issued to the individuals at the point of admission. These included the terms and conditions of residence at the home, the room number to be occupied and who was responsible for paying the fees. Beeton Grange DS0000064739.V353724.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care plans did not always detail the specific needs of the people living in the home and how staff were to support them to meet these needs. Some risk assessments needed to be further developed to ensure all risks were minimised. The people living in the home were supported and enabled to make decisions about their lives on an ongoing basis. EVIDENCE: The system in place for care planning at the home had been updated and staff had worked hard to up date all the care plans. The files for three of the people living in the home were sampled. Two of these had only recently moved into the home, the other person had lived there for two years. All the files included numerous care plans which had been identified as needed on the assessments that had been undertaken. The care plans were generally quite comprehensive and detailed where support was needed and the type of Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 12 support that was to be offered by staff. Care plans detailed such things as the individuals’ abilities to tend to their personal care needs, their dietary preferences and their ability to prepare and cook food. The people living in the home came from different cultural backgrounds and their needs in relation to this were generally well detailed. However in some instances this needed to be expanded, as they were none specific. For example, one of the care plans stated ‘will be provided with support and opportunity to engage in religious, social or cultural activities.’ This did not tell staff what support the individual needed or what her preferred activities or cultural needs were. Some of the staff in the home were from the same cultural background and would have known what was appropriate to offer others would not. All the files sampled included very good care plans detailing how staff were to monitor the health care needs of the individuals. Care plans were being evaluated and there were weekly progress reports written by staff. However there was no evidence to suggest that the progress or otherwise to meeting the needs of the individuals was discussed with them on an ongoing basis. The individuals spoken with were aware of their care plans and the risk assessments in place. It was recommended that the suitability of care plans and how they were progressing were regularly discussed with the people living in the home and that records of these discussions were maintained. There were numerous risk assessments in place on the files sampled. Some of these were very unlikely to identify any issues for the people living in this home, for example, manual handling and pressure care, but were done as they were part of the organisations file format. Two of the three files sampled had relapse strategies in place that were very detailed and included triggers, how it manifests at different stages prior to relapse and then what to do in the event of a relapse. The manager could not explain where the relapse management plan had gone in the third file as it had definitely been done. A copy of this was e-mailed to the inspector the day after the inspection. Other risk assessments and management plans were in place for such things as, refusing medication, going missing, self neglect, delusional behaviour and general safety, for example smoking. The manager needed to ensure that the management plans in place for risks were all comprehensive. For example one of the files identified the individual could have some challenging behaviour, be very aggressive and displayed sexually provocative behaviour. The management plans in place stated such things as ‘monitor and report’ this did not inform staff how they were to manage the behaviour at the time it happened. Clearly the people living in the home were encouraged to make decisions on a daily basis. This was evidenced throughout the inspection with individuals coming and going from the home as they pleased, within the bounds of their risk assessments, choosing what they were going to cook, how they were going to spend their day, having friends visit them in the home and so on. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to support the choices of the people living in the home about their lifestyle, including their aspirations, promoting independent living and cultural identities. EVIDENCE: The people living in the home were assisted within the home to develop and maintain life skills such as budgeting, shopping, domestic skills and cooking. They spoke to the inspector about going out shopping for food, doing their laundry and keeping their rooms tidy. There are two distinct sides to the building (phase one and phase two). Phase one supports people who require more staff involvement and phase two is for people who are more independent and who require reduced support from staff. This is reflected in the staff allocations, and the people living in the home confirmed there is always staff available to help them if needed. Activities Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 14 were arranged that reflected the cultural and religious needs of the people living in the home and were dependent on what stage they were at in their rehabilitation. Clearly from the records seen and the activities board a range of activities were available for the people living in the home. These included going out for meals, to the cinema, day centres, visits to the temple or the mosque, college courses and so on. One of the people living in the home spoke about going to college to get some more training doing bricklaying, tiling and plastering. Another spoke of going to a centre two days a week to do some assembly work and attending the Asian women’s day centre. Another spoke of his love of music and he spent a lot of time playing his guitar. One of the people living in the home was helping in the office and appeared to enjoy this answering the phone and the door. The people living in the home were seen to come and go as they wished throughout the day of the inspection within the bounds of any risk assessments in place. If any risks had been identified of people going missing or being very vulnerable in the community a management plan was in place. Personal and family relationships were clearly detailed in the individuals care plans. There was ample evidence that the people living in the home had contact with their families on a regular basis wherever possible and staff supported them with this where necessary. Where necessary management plans had been put in place for supervised visits. Some of the people living in the home spoke to the inspector about spending Christmas with family, others of staying at the home and their relatives visiting. The inspector was told that each side of the home had their own menus which were done on a weekly basis in consultation with the people living in the home. Some of the people living in the home did all their own cooking and shopped for their own provisions, others cooked occasionally others were not able to do any cooking. Those spoken with were satisfied with the catering arrangements in the home and the menus on display were varied and nutritious. It was difficult to track exactly what people were eating as this was not always recorded. Staff should try and record what the people living in the home are eating to evidence they are having a varied and nutritious diet. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The personal and healthcare support offered and provided to the people living in the home met their diverse needs. The medication system was generally well managed. To ensure the system was entirely safe staff needed to ensure they only signed for medication when it was given. EVIDENCE: Care plans included details of the personal and health care support needs of the individuals. The support needed by the people living in the home for personal care was varied. Some were independent, some needed minimal promoting others needed more support. The people living in the home were seen to dress according to their preferred choice, age and cultural background. Mental health teams were actively involved in the care of the people living in the home, including social workers, community psychiatric nurses and psychiatrists. All the people spoken with confirmed they had regular contact with their mental health workers. All files included professional visits sheets that detailed who had visited, the reason for the visit and the outcome. This Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 16 detailed visits from mental health workers including CPNs for such things as injections, medication reviews and delivering medication. Mental health monitoring care plans were in place. There were risk assessments in place for health care issues, for example, asthma attacks. It was noted one of the people living in the home was having their blood pressure checked but there was no detail on the records of what was the acceptable range for this and when staff needed to alert senior staff. This was raised with the manager. The day after the inspection this was addressed and a care plan had been put in place. At the last inspection issues were raised about the people living in the home receiving their post and not telling staff when they had medical appointments leaving them at risk of missing appointments. This had been addressed at the time of this inspection and risk assessments had been undertaken where necessary. One of these were seen and the person had agreed to open his post in front of staff so they could verify there were no appointments included. All the people living in the home were registered with a G.P. and all were being weighed monthly. The medication in the home was mostly administered via a 28 day monitored dosage system and boxed medication was minimal. The inspector was informed that only staff that had received appropriate training administered medication. For each of the people living in the home there was a photo, a medication administration record (MAR), a copy of the GP’s prescription and where known a record of allergies. A random audit of the boxed medication was undertaken. Some discrepancies were noted in the amounts of tablets delivered to the home, what had been administered and what remained in the boxes. It was also noted that for one lot of medication it had not been carried forward onto the new MAR chart and staff were recording on the back of the MAR chart when administered. Also the home were keeping paracatemol as a homely remedy and although it was recorded on individual MAR charts when administered there was no audit trail for this medication. When the people living in the home were taking medication out with them they were signing for it. No controlled drugs were being administered in the home at the time of the inspection. Risk assessments had been undertaken for all the people living in the home should they refuse their medication. The manager of the home was surprised at the discrepancies found in the medication system as the system is regularly audited. The day after the inspection a full investigation was undertaken by the manager of another home. A report of this was sent to the inspector and was very thorough. It appeared that for two of the discrepancies an accounting error had been identified where staff had not brought medication forward from the previous Mar chart or had not counted the medication correctly when delivered to the home. Only one of the errors could possibly have had a negative affect on the individual, as it appeared staff had signed for medication that had not been Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 17 administered. This was immediately referred to the G.P. The inspector was informed that as a result of the investigation all staff were to receive refresher training for medication administration and the manager would be undertaking weekly audits. The inspector was also informed that a system for auditing the paracetamol had also been put in place. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 18 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The views of the people living in the home were listened to and acted on. The systems in place and the training staff had received ensured the people living in the home were safe guarded. EVIDENCE: The home had an appropriate complaints procedure and this was detailed in the service users guide. All the people living in the home were issued with a service user guide with this information. One of the surveys returned to the Commission by one of the people living in the home indicated they did not know how to make a complaint. This was not reflected in the other surveys or by the people spoken to during the course of the inspection who all indicated they would go to a senior member of staff and were confident any issues would be addressed. One survey from a relative indicated they knew how to raise any concerns and they stated: ‘Never have cause to complain.’ The home had not logged any complaints since the last key inspection and none had been logged with the Commission. The procedures for adult protection were not viewed at this inspection but have been found appropriate at previous inspections. No issues of adult protection have been raised at the home since the last inspection. The AQAA stated that Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 19 staff had received refresher training in abuse and protection of vulnerable adults. This was evidenced in the training matrix for the home. The home operated a system for the safe keeping of money on behalf of the people living in the home. The records that were sampled for this were appropriate and all balances were correct. Some of the people living in the home managed their own finances others left money in the safe of the home and would draw it as they needed it. The individual and a member of staff signed for any withdrawals. The system was also audited periodically by the organisation. Beeton Grange DS0000064739.V353724.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, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides the people living there with a comfortable, clean and homely environment in which to live which meets the group and individual needs. EVIDENCE: A tour of the home was undertaken and some bedrooms were seen. The home was safe and generally well maintained. Any issues raised were generally minor and the manager was already aware of them and was planning to have them addressed, for example, the work surfaces in one of the kitchens needed to be replaced and the sofas in one of the lounges were showing signs of wear and tear. Since the last inspection several areas had been redecorated and the decorators were due back in the home in February. The issues raised at the last inspection in relation to the exterior brickwork at the back of the home and the emergency call system cord had been repaired. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 21 The home is divided into two sides phase one and phase two. Both areas had very large, pleasant lounges, one had been decorated and the other was due for decoration in February. The furnishings had been replaced in one of the lounges the other was to have new furnishings after being decorated. Both lounges were equipped with televisions and stereo units. Both phases had a kitchen and dining area. One of the kitchens needed to have the work surfaces replaced as they were worn but this was planned for this year. One of the dining areas was being used as a smoking area at the time of the last inspection. This had changed and smoking was not allowed in any communal areas. A smoking shelter had been put in the garden for the use of the people living in the home. The bedrooms that were seen varied in size and were personalised to the occupants choosing. All the people living in the home that were spoken with were satisfied with their rooms. They had keys and could lock their doors for privacy if they wished. Both phases of the home had a bathroom and shower room. Both shower rooms had been refurbished since the last inspection and one of the bathrooms had had a new bath installed. One of the bathrooms had damaged flooring which needed to be replaced. The laundry was on the ground floor of the home and equipped with two washing machines, two driers and facilities for ironing. The home was found to be clean and hygienic. The completed surveys sent to the Commission indicated that the people living in the home thought it was always clean. One relative commented: ‘The whole place is well kept. It is clean.’ Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The people living in the home were supported by a stable, well trained staff team that were available in suitable numbers. The recruitment procedures were robust and safeguarded the people living in the home. EVIDENCE: The manager stated the home was fully staffed at the time of the inspection and that there had been little staff turnover since the last inspection. Many of the staff had worked at the home for a considerable amount of time which was very good for the continuity of care of the people who lived in the home. It was evident throughout the course of the inspection that there were good relationships between the staff and the people living in the home. Comments they made included: ‘I get on O.K. with staff.’ ‘I like the staff. They generally listen.’ ‘Staff are fine, enough staff around.’ Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 23 One relative commented: ‘They are co operative, they try their best.’ Staffing levels were appropriate for the needs of the people living in the home at the time of the inspection. As well as support workers the home also employed domestic assistants, an administrative worker and maintenance workers. The staff team clearly reflected the cultural backgrounds of the people living in the home. The inspector was informed only one new member of staff had been employed at the home since the last inspection. The recruitment records for this individual were checked. All the required documentation was in place. All the appropriate checks had been undertaken prior to the person commencing their employment including CRB clearance, medical checks and two written references. There was evidence on the new employees file that a 16 week induction training programme had been undertaken. This was quite extensive and evidenced that training such as adult protection and food hygiene were undertaken during this period. However the programme needed to be cross referenced to the Skills for Care induction specification to ensure all areas were covered and that it was completed within the specified 12 week time scale. The inspector was given an extensive training matrix for the home. This indicated staff had undertaken all their regulatory training including fire safety, food hygiene, moving and handling, health and safety and infection control. Staff had also undertaken a variety of other training relevant to their roles such as, substance abuse, epilepsy, mental health and customer care. The training matrix also indicated that ten of the twenty care one staff had achieved NVQ level 2 or 3 which is slightly below the required fifty percent. However seven staff were undertaking their NVQ level 2 training which will give the home well above the required percentage when completed. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has demonstrated that it does have the ability to ensure that the management and administration is run in the best interests of the people living in the home, that its operation has a focus on choice, inclusion and promoting the health and safety of all the people in the home. EVIDENCE: The registered manager had worked at the home for a considerable amount of time and had a lot of experience of caring for people with mental health needs and the running of a residential home. The people living in the home stated they liked the manager one described her as ‘marvellous’. She was clearly very accessible to them throughout the course of the inspection and she had a very Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 25 good knowledge of their needs. The training matrix for the home indicated that the manager regularly updated her training along with the staff team. The home had a quality assurance system in place. This involved the manager undertaking in house audits on a variety of areas including health and safety, care plans accidents and so on. A representative from the organisation then validated the audits. Comments made on the reports by the representative included: ‘excellent home with a warm friendly atmosphere’ and ‘needs of the service users well attended to.’ There was evidence on site of regular meetings with the people living in the home. Topics discussed included unacceptable damage in the home, smoking, repairs, activities, suggested trips out and disagreements. There was also evidence of regular staff meetings. No issues were raised in relation to health and safety at the time of this inspection. The AQAA detailed that all the equipment in the home was serviced as required. The in house checks on the fire system were all up to date, regular fire drills were undertaken and staff had received fire training. There was also evidence on site that such things as window restrictors and the emergency call system were regularly checked. Accident and incident recording and reporting were appropriate. Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 26 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 3 X 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 2 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 3 X X 3 X Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 27 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 YA9 Regulation 13(4)(c) Requirement Risk management plans must specifically detail how staff are to manage situations as they arise. This will ensure that the people living in the home and staff are not exposed to unnecessary risks. Staff must ensure they follow the medication policies and procedures for the home. Staff must ensure they sign for medication as it is administered. This will ensure the people living in the home receive their medication safely and as prescribed. Timescale for action 14/02/08 2. YA20 13(2) 14/02/08 Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 28 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. Refer to Standard YA6 Good Practice Recommendations Care plans should detail all the needs and the support staff are to give to the people living in the home to enable them to meet their needs. This will ensure the people living in the home receive person centred care. It is recommended that the suitability of care plans and how they are progressing are regularly discussed with the people living in the home and that records of these discussions are maintained. Staff should try and record what the people living in the home are eating to evidence they are having a varied and nutritious diet. It is recommended that the damaged bathroom flooring is replaced. This will ensure the home is kept to an acceptable standard for the people there. It recommended that 50 of staff are qualified to NVQ level 2 or the equivalent. This will ensure staff have all the necessary skills and knowledge to support the people living in the home. The induction training programme for new staff should be cross referenced to the specifications laid down by Skills for care to ensure it covers all the necessary areas and is completed within the given time scale. This will ensure new staff are equipped with all the necessary skills and knowledge to support the people living in the home. 2. YA6 3. 4. 5. YA17 YA27 YA32 6. YA35 Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Beeton Grange DS0000064739.V353724.R01.S.doc Version 5.2 Page 30 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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