CARE HOME ADULTS 18-65
Beighton Road 100 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PS Lead Inspector
Ms Shelagh Murphy Unannounced Inspection 09:30 3 November 2005
rd Beighton Road DS0000002938.V261105.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 Beighton Road DS0000002938.V261105.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. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Beighton Road Address 100 Beighton Road Woodhouse Sheffield South Yorkshire S13 7PS 0114 269 9359 0114 269 3531 tony.veeren@virgin.net 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) South Yorkshire Housing Association Mr Mootoosamy Tony Veeren Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 27th April 2005 Brief Description of the Service: Beighton Rd offers services for up to eighteen adults with learning disabilities. The service is located in the Woodhouse area of Sheffield, close to local facilities such as shops and a health centre. The home is close to a local bus route. There are three detached houses on the site. Each one offers accommodation to six service users. Each house has a separate kitchen and laundry facilities. They all have large dining/lounge areas and all of the bedrooms are single. There is a large garden area and a car park. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place from 9.30 to 12.40pm. Previous requirements were checked, as were the key standards, not checked at the previous inspection. An inspection of each house was carried out. The service users 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. However, several service users spoke to the inspector informally. The inspector spoke to several members of staff and the manager of the service. A number of records were checked and feedback was given to the manager, and deputy manager. What the service does well:
Overall, the environment within the home is clean, well decorated, comfortable and homely. Several of the residents said they enjoyed living at the home. There was a calm and relaxed atmosphere in all of the houses. The service users seemed happy and were interacting with staff in an appropriate and warm manner. The staff were very respectful of the service users and spoke of individuals with positive regard. The home has a stable staff team, who know the residents very well and who have developed supportive relationships with residents and relatives. The residents said they liked the staff that worked at the home. The resident’s bedrooms were well decorated, comfortable and reflected personal choice. Several residents were keen to show the inspector their rooms and said they had chosen colour schemes and furnishings. Most residents are encouraged to take part in appropriate independent living skills and daily activities, which enabled them to develop skills and take part in meaningful activities. The deputy manager and the staff said that the opportunities to access the local community facilities had improved since the service had employed more support workers last year. The medication procedures were checked and medication administration was found to be managed in a safe way. All staff were thoroughly trained prior to giving out medication to service users and the team leaders check the medication administration records on a regular basis. There were no problems found with the system at all. Fifty percent of the staff team had professional nursing qualifications or NVQ2/3 care awards. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection?
In house two the kitchen was being replaced and there were plans to refurbish the laundry area. The manager said that all of the kitchens and laundry areas would eventually be refurbished to improve the environment of the houses. Care plans had been reviewed on a six monthly basis; the staff were now using a person centred approach in the way service users individual plans were being devised. The deputy manager said there were plans to devise person centred plans for all of the service users in the future. The three cook/housekeeper posts have been advertised and the manager said that interviews were taking place this week to fill these posts. He also confirmed that several support workers had recently been recruited to ensure the home was appropriately staffed to meet the service users needs. All of the staff had completed adult protection training since the last inspection, in order to develop the staff knowledge of the issues in order to protect the service users. The table in the dining room of one of the houses had been re-varnished and now looked clean and fit for purpose. The carpet in the lounge had been cleaned but was still showing signs of stains. The manager said they had ordered a new carpet to be fitted when all of the refurbishment in the kitchen had been completed to ensure the service users were living in clean and well-kept accommodation. In one house the toilet flooring had not been replaced but had been cleaned and mats were now used which could be cleaned on a regular basis. This had eradicated the odour and staining on the floor covering in this room. Two staff had started the Learning Disability Award Framework (LDAF) induction and foundation training to ensure they have a basic understanding of the needs of the service users who live at the home. Staff training records had been updated. When these were checked it showed that all of the mandatory training had been completed by the staff except for First Aid and the manager confirmed that staff would be completing this training before the end of 2005 to ensure the staff had adequate training to carry out their roles safely. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 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. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 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 Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. None of these standards were checked on this inspection. Standard 2 was checked at the last inspection and was met. EVIDENCE: Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6. The service users needs and personal goals were reflected in the individual plans checked. EVIDENCE: Three service users individual care plans were checked they were very comprehensive, contained all of the information required by the regulations and had been reviewed on a six monthly basis. A person centred approach had been used in the way the plans were drawn up. There was evidence that the service users, their relatives and other key people had been involved in the review meetings. Beighton Road DS0000002938.V261105.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): 15 & 16. Service users were supported to have appropriate relationships with peers, relatives and friends. The staff showed respect for the service users’; in the way they spoke to and addressed them. The residents were observed to be offered choices and were supported to make everyday decisions. EVIDENCE: Through discussions with the deputy manager, from reading three care plans And through informal discussions with service users it was clear that staff support service users to maintain relationships with their relatives either by phone or visits. One of the service users told the inspector they were visited on a regular basis by family members. Several service users described other people who lived in the home as their friends. The deputy manager said one service user had an advocate. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 12 Staff were observed to treat resident’s with respect as they knocked on the service users doors before entering, addressed service users by their preferred names and spoke of the residents with regard. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. None of the service users were responsible for self-medication due to their support needs; risk assessments had been devised for this purpose. The service had robust medication policies and procedures in place to protect the service users from risk. EVIDENCE: Three of the service users medication sheets and nomad boxes were checked. They all met the required standards. The home had robust policies and procedures in place, which ensured that staff were trained and mentored prior to administering medication independently. There were checking systems in place to ensure that any anomalies are highlighted as early as possible and the senior staff did regular checks. All medication was found safely stored and there was evidence that a local pharmacist visited regularly to monitor the systems in place. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Service users were protected from abuse, neglect and self-harm by the homes policies and procedures. EVIDENCE: At the last inspection a requirement to ensure all appropriate staff had the opportunity to complete adult protection training was made, as this was the only area of the standard, which had not been met. Staff training records were checked and showed that all of the appropriate staff had received this training since the last in section in order to protect the service users. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 29 & 30. Overall, the environment within the home is clean, well decorated, comfortable and homely. Several of the residents said they enjoyed living at the home. Kitchens and laundry facilities need to be refurbished in each house to ensure the service users are living in a homely and clean environment, which can meet their needs. The service users bedrooms were all individually decorated and furnished to meet their needs and personal choices. The needs of some service users in each of the houses have changed over the years. Service users present needs in relation to bathing and showering are not all being met safely. This means that all of the relevant people need to be assessed to identify the most appropriate specialist baths/showers to be fitted to meet their needs. The houses were generally very clean and hygiene standards were good. EVIDENCE: The houses were all generally clean, comfortable, and homely and met the needs of the service users.
Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 16 The resident’s bedrooms were all well decorated, comfortable and reflected personal choice. Several residents were keen to show the inspector their rooms and said they had chosen colour schemes and furnishings. In house two the kitchen was being replaced and there were plans to refurbish the laundry area. The manager said that all of the kitchens and laundry areas would eventually be refurbished to improve the environment of the houses. Therefore houses 1 and 3 need to have new kitchens fitted and their laundry facilities refurbished to provide an environment, which is homely and fit for purpose The table in the dining room of one of the houses had been re-varnished and now looked clean and fit for purpose. The carpet in the lounge had been cleaned but was still showing signs of stains. The manager said they had ordered a new carpet to be fitted when all of the refurbishment in the kitchen had been completed to ensure the service users were living in clean and well-kept accommodation. The carpets in house 2 on the hallways, stairs and lounge need to be cleaned or replaced, as they are dirty and stained. In one house the toilet flooring had not been replaced but had been cleaned and mats were now used which could be cleaned on a regular basis. This had eradicated the odour and staining on the floor covering in this room. In houses 1, 2 & 3 professional assessments need to be carried out to identify what kind of specialist bath/showers could best meet the needs of the service users, this equipment then needs to be fitted to ensure the service users can bathe in a safe manner, with appropriate equipment to meet their mobility needs. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 17 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): 33, 35 & 36. The home has a stable staff team, who know the residents very well and who have developed supportive relationships with service users and their relatives. Action had been taken to fill the vacant cook/housekeeper posts and interviews were planned for later in the week. Several support workers had recently been recruited to ensure sufficient staff, were available to meet minimum staffing levels to meet the residents needs. LDAF training had been offered to two of the staff team and fifty percent of the staff team had completed the NVQ2/3 training before the end of 2005. Training records had been completed and these clearly showed that the appropriate staff had completed most of the mandatory training required to ensure they could carry out their duties in a safe manner. The only training which now needed to be offered was first aid. EVIDENCE: The staff said that communication within the staff team was good, that they had adequate training and support from managers and felt empowered to make some decisions within the service. The home has a stable staff team, who know the residents very well. The staff said they had close working relationships with the service users relatives.
Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 18 The three cook/housekeeper posts have been advertised and the manager said that interviews were taking place this week to fill these posts. He also confirmed that several support workers had recently been recruited to ensure the home was appropriately staffed to meet the service users needs. Two of the staff had been offered the opportunity to complete the LDAF induction and foundation training. The deputy manager said that the home had met the target to have 50 of the staff team with the NVQ2/3 care award by the end of 2005. Training records showed that all of the staff had been given the opportunity to complete all of the mandatory training required with the exception of first aid training, which had been planned to take place later in the year. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 19 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): None. None of these standards were checked on this inspection. Standards 37, 39 and 42 were checked at the last inspection and were met. EVIDENCE: Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 20 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 X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 3 X X X 2 2 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 X 2 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Beighton Road Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000002938.V261105.R01.S.doc Version 5.0 Page 21 No. Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA24 YA24 Regulation 23 23 Requirement The kitchens and laundry facilities must be refurbished in each house. Carpets throughout the houses must be checked and any dirty or stained carpets must be cleaned or replaced. Appropriate assessments to identify the service users needs in each of the houses in relation to bathing equipment must be carried out. Appropriate action must then be taken to ensure the specialist equipment identified is supplied and fitted in each house. All appropriate staff must be offered the opportunity to complete first aid training. Timescale for action 30/06/06 31/03/06 3 YA29 16 30/06/06 4 YA35 18 31/03/06 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 Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 22 NA NA NA. Beighton Road DS0000002938.V261105.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Sheffield Area Office 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 DS0000002938.V261105.R01.S.doc Version 5.0 Page 24 - 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!
