Inspection on 27/04/05 for Beighton Road

This inspection was carried out on 27th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 but made no statutory requirements on the home.

Other inspections for this house

Beighton Road 27/04/06

Beighton Road 03/11/05

Beighton Road 01/09/04

Beighton Road 06/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Beighton Road 100 Beighton Road Woodhouse Sheffield S13 7PS Lead Inspector Claire McAuley Unannounced 27th April 2005 09:30am 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 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 Stationary 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. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 3 SERVICE INFORMATION Name of service Beighton Road Address 100 Beighton Road Woodhouse Sheffield S13 7PS 0114 2699359 0114 2693531 None South Yorkshire Housing Association Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Mootoosamy Tony Veeren PC Care Home Only 18 Category(ies) of LD Learning disability (18) registration, with number of places Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st September 2004 Brief Description of the Service: Beighton Road offers services for up to eighteen adults with learning disabilities. The service is located in the Woodhouse area of Sheffield, close to local facilities including shops, and bus routes. There are three separate houses in the grounds, which offer accommodation for up to six people each. The three houses have kitchen and laundry facilities, and a communal lounge/dining room. All of the bedrooms are single. There is a large garden area and car park. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place from 9.30 to 13.00. Previous requirements were checked and the majority of key standards. A tour of the building took place. The tenants who were at home at the time of the inspection were unable to express a view on the quality of care they received due to their learning disability. The inspector spoke to two members of staff. A number of records were checked and discussions with the manager, and deputy managers took place. What the service does well: What has improved since the last inspection? The majority of requirements and recommendations from the previous inspection had been completed. Work had taken place on developing a Person Centred approach to the plans of care, which were of a high standard. Support staff had been recruited by the home and staffing levels were now sufficient to enable support staff to assist tenants with more leisure and work activities and outings outside the home. Quality assurance systems had been developed, and a Tenants Participation Officer had been employed by South Yorkshire Housing and had produced the first Tenant’s newsletter. The target of 50 of staff members with NVQ2 or above qualification had been met, and the manager had achieved his NVQ4 qualification. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 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 Standards Statutory Requirements Identified During the Inspection Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 2 Tenants needs were fully assessed and appropriate plans of care were in place. EVIDENCE: The manager confirmed that no new tenants were admitted to the home without a full needs assessment being undertaken by a social worker or other appropriate professional. Individual plans of care were developed, with tenants, based on comprehensive assessments. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 6 7 8 9 Care plans were of a high standard and addressed all the needs of the tenants and action staff should take. Service users were encouraged to make decisions about their own lives. Risk assessments identified where tenants needed assistance to maintain their health and safety. EVIDENCE: Care plans seen were of a high standard and covered all of the required information. They were based on person centred planning principles. -A small amount of updating on care plans was required. Service users were involved in making decisions about their own lives, including holidays. Advocates were available. Tenants were consulted on their opinions in relation to the running of the home including shopping and choice of food. Tenants meetings regularly took place. A survey on tenants and their relatives/representatives opinions on the home had taken place. Tenants were unable to be involved in all aspects of the running of the home due to their learning disabilities. Risk assessments were in place in care plans. They were detailed and identified tenants at risk and those with challenging behaviour. Programmes of staff action to limit these situations were included, and focused on positive behaviour. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 10 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 standard(s) 11 12 13 14 16 17 Tenants were supported to maintain and develop social, educational, communication and independent living skills. Spiritual and emotional needs were met. Appropriate activities were offered. Tenants participated in the local community. There was still a shortage of domestic staff which meant staff could not involve tenants as much as they would like in activities of daily living. Menus were chosen by tenants and were well balanced. EVIDENCE: Tenants had opportunities to maintain and develop social and independent living skills. Their personal development focussed on meeting emotional and spiritual needs. Some tenants were supported by speech therapists to develop communication skills and there was access to advocates who were able to support them as needed. Tenants were able to take part in age, peer and culturally appropriate activities, including employment training schemes and college courses. Some tenants went to a weekly luncheon club, and others attended day centres. Support staffing levels had improved and staff were able to accompany tenants on trips outside the home more frequently. All tenants were able to participate in the local community, including shopping and going to the local pubs, hairdressers and leisure centres. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 11 Tenants had the option of a minimum seven-day annual holiday outside the home, which they could help to choose and plan. The home had a range of leisure facilities, such as jigsaws, books, television, videos and music. The daily routines in the home were arranged around the tenants and appeared flexible. There was still a shortage of housekeeping staff and support workers were not able to engage tenants in independent living activities as much as they would have liked to. Menus were chosen by the tenants. There was also a lot of flexibility in choosing food on a daily basis. The menus were nutritious and included fresh fruit and vegetables. Information on healthy eating was provided. Nutritional needs and preferences were recorded and tenants were given appropriate assistance. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 18 19 Staff were supportive and helped tenants to choose their daily routines. There were appropriate technical aids provided to meet individual needs. Health needs were met and monitored and tenants were helped to identify their own needs through pictorial care plans. EVIDENCE: Staff provided sensitive and flexible personal support. Tenants were encouraged to choose times to get up, go to bed, baths, meals, clothes, and hairstyles etc. There were technical aids and equipment provided by the home. This equipment was determined by professional assessment, and reviewed and changed as the tenant’s needs changed. The care plans had pictures, such as a foot to indicate Chiropodist, ensuring that tenants could easily identify the different sections of their care plan. Each file had a section to record visits, treatment and identified future needs relating to healthcare professionals. Access to Psychologists, Speech Therapists, Continence Advisors and Specialist Nurses had been provided where there was an identified need. Health was monitored, and weight checks took place. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 22 23 Tenants were appropriately protected. Staff were knowledgeable about the complaints procedure, which was also presented in a pictorial format so that tenants could understand it. There was an adult protection policy and procedure in place and any allegation of abuse was referred to Social Services Adult Protection procedures. EVIDENCE: The home had a complaints procedure. One complaint had been received in the last 12 months, and this was under investigation. The complaints procedure had been updated to include information in a pictorial format for tenants. There was an adult protection policy and procedure in place. Any allegation of abuse was referred to Social Services Adult Protection procedures. Staff had not received specific adult protection training to ensure the safety of tenants. There were appropriate measures in place to deal with physical or verbal aggression by tenants, and any sanctions imposed were time limited and regularly reviewed. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 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 standard(s) 24 30 The home was generally comfortable, clean, safe, and furnished and decorated to a good standard. Tenants rooms were individually personalised. Laundry facilities were suitable to meet the needs of the tenants. EVIDENCE: The home’s environment was generally of a good standard. All three houses were clean and fresh smelling. Furnishings and furniture were of a good standard, and tenants rooms were personalised. The home had a maintenance and renewal programme in place. Carpets in a bedroom and a lounge were stained, and flooring in a toilet was stained and worn. The tables in a dining area were worn and marked. There was a pleasant and extensive garden area which was mainly lawned and easily accessible to tenants. Each house had its own laundry, which was suitably equipped. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 33 34 35 36 Tenants were supported by staff who had a good knowledge of their needs and who had received appropriate training. Numbers of staff to support tenants were appropriate, although more cook/housekeepers were required to enable support staff to spend more time with tenants. Recruitment procedures protected tenants by ensuring CRB and POVA checks were completed. Supervision of staff was appropriate to meet service users needs. EVIDENCE: Staff demonstrated a good knowledge of how to meet the needs of individual tenants. A key worker system and person centred planning was in place to promote this. Rotas confirmed that the required number of staff were on duty. Since the previous inspection staffing numbers had been increased and this enabled staff to spend more time supporting tenants. However, there was still a shortage of cook/housekeepers at the home. The home had reached its target of 50 of staff trained to NVQ 2 or above. Recruitment procedures at the home included all the required information and all CRB and POVA checks were completed. LDAF induction and foundation training had not been completed. However the home had an induction and training programme, which was regularly updated. included all mandatory training and identified individual training needs. To ensure the safety of tenants, staff training records needed to be fully completed. Staff supervision took place at the required level. Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 42 Quality assurance systems ensured that tenants and their representative’s views on all aspects of the home were included in developments and changes. A health and safety policy was in place. Staff had received appropriate training, and appropriate recording of accidents and risk assessments was in place. This enabled a safe environment to be maintained. EVIDENCE: A South Yorkshire Housing Quality Assurance Officer visited the home each month and tenants meetings took place monthly and weekly. Relatives and representatives of tenants were invited to these meetings. The home had an Annual Development Plan, and a Newsletter in which tenants could express their views. Quality audits on the environment and other aspects of the home were in place. A recent survey to discover the views of tenants and their representatives had taken place. These systems ensured that the quality of care and the environment was maintained, and any changes at the home included information received from tenants and representatives. The home had a health and safety policy and staff had received training in health and safety, moving and handling, fire safety, first aid, food hygiene and infection control. No fire exits were blocked and hazardous substances were Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 17 securely stored. Regular maintenance of all systems and equipment took place. There were appropriate measures in place to ensure the security of the premises and prevent intruders. Window restraints were in place. Risk assessments were appropriately undertaken and revised. Accidents were appropriately recorded and reported. 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 x x x Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 3 Standard No Beighton Road Standard No 31 32 Score 3 3 Version 1.20 Page 18 J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc 11 12 13 14 15 16 17 3 3 3 3 3 2 3 33 34 35 36 2 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 3 x Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 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. 2. 3. 4. 5. 6. 7. Standard 6 16 33 23 24 24 24 33 35 Regulation 15 18 13 23 23 23 18 Requirement All plans of care must be fully updated. All vacant cook/housekeeper posts must be recruited to. All staff must receive adult protection training. Carpets in the bedrooom and lounge must be cleaned. Tables in the dining room must be revarnished, or replaced. The stained worn flooring in the toilet must be replaced. All appropriate staff must complete the LDAF induction and foundation training. (Previous timescale of 31st December 2004 not met). Staff training records must be fully completed. Timescale for action 1st August 2005 1st August 2005 1st August 2005 30th June 2005 30th June 2005 1st August 2005 1st August 2005 8. 36 18 30th June 2005 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 6 Good Practice Recommendations Medication sheets in plans of care should be legible and regularly updated. J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 20 Beighton Road Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 21 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Beighton Road J55 S2938 Beighton Road V218813 27.04.05 UI Stage 4.doc Version 1.20 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!