Inspection on 10/08/05 for Belchford

This inspection was carried out on 10th August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Belchford 24/05/07

Belchford 24/05/06

Belchford 31/01/06

Belchford 12/11/04

Belchford 12/05/04

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

CARE HOME ADULTS 18-65 Belchford Hesleden Road Hesleden Blackhall, Hartlepool TS27 4PB Lead Inspector Stephen Willcock Unannounced Inspection 10 August 2005 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. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Belchford Address Hesleden Road Hesleden Blackhall Hartlepool TS27 4PB 01429 836286 01429 836286 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) Milbury Care Services Limited Care Home 8 Category(ies) of Learning Disability (8) registration, with number of places Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th November 2004 Brief Description of the Service: Belchford provides resident ial care for up to seven people who have a learning disability. The home is a detached house with large grounds, in a rural setting. The centres of Durham and Peterlee are easily accessible by car. The home is managed by Milbury Care, an organisation that specialises in services for people with a learning disability and has recently become part of the Paragon Group. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 10th August 2005 and lasted around 5 hours. Time was spent talking to staff and the manager. We looked around the building and at a number of records and documents. Since the last inspection a new manager has been appointed and is awaiting registration with the Commission for Social Care Inspection. The home was very pleasant and the service users who were at the home on the day appeared happy and well cared for. The gardens are large and could be made a lot better for service users as some areas are little used. The manager said there were plans to redevelop the kitchen and dining areas and to refurbish the bath and toilet facilities. What the service does well: What has improved since the last inspection? The manager has worked well to meet the requirements and recommendations given at the last inspection. A clear direction of management was evident and enthusiasm to improve the service was seen. Staff training was continuing and included courses specific to the meeting and understanding the needs of the service user group. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 6 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. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 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 Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 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) 1, 2 and 4 The home provides satisfactory information in appropriate formats, to enable service user choice about living at the home. EVIDENCE: Information was available for prospective service users to decide whether to stay at the home. The Statement of Purpose and Service user Guide were informative and available in a pictorial format. Both documents were to be further reviewed to include photographs of the home to ensure the contents were easily accessible to service users. Assessment documents for individual service users were seen to be in place. The documents contained original assessments from social workers and also the homes own assessments conducted prior to admission. At the time of the inspection a prospective service user was visiting the home prior to making the decision to live there. Evidence was available to show that service users are invited to stay at the home after a process of trial visits including staying for tea and overnight stays before moving in. Assessments are carried out during this time and over a full 24 hours. Reassessment is carried out to ensure the service users needs are met by the home. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 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 and 9 Care plans are prepared and reviewed with each service user. Risk assessment is carried out to cover many aspects of daily life and activity. EVIDENCE: Individual service user care plans were examined and found to be informative and comprehensive. The plans were available in a pictorial format and held evidence of service user involvement. A file giving descriptions of individual service user’s communication methods had been prepared and was noted as being invaluable to staff members in conducting effective communication and links had been made with speech and language specialists to assist this process. Service user case files showed that risk assessments were in place for a variety of activities and included specific assessments relating to personal care and everyday activity. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 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) 14 and 17 The home provides satisfactory leisure and community interests. Meals and mealtimes are flexible and respect service users choice. EVIDENCE: There are a number of outside leisure interests pursued by service users including visits to places of interest, swimming, horse riding and going to the local pubs. The home has the use of its own transport for these occasions. Menus are prepared with service user involvement and are flexible to meet the choice of food requested on a daily basis, within a balanced diet dependent upon dietary need. Alternatives to the menu are readily available. Mealtimes are flexible and service users are often encouraged to participate in the preparation of the table and meal. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 11 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) 20 Procedures are in place to assist a service user to control their medication if requested. EVIDENCE: Examination of medicine administration records found them to be well kept and accurate. There were no service users who were self-medicating but the manager was able to outline the homes procedures of risk assessment and monitoring should a service user wish to develop self-medicating skills. Consent to administer medication on behalf of the service users had been obtained. Staff at the home had undergone college training in the administration of medication along with the homes policies and procedures on medication. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 12 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 and 23 The home operates a thorough complaints procedure and can demonstrate good knowledge of Adult Protection issues and procedures. EVIDENCE: A complaints policy and procedure was made available that included timescales and stages of the complaints process. The manager said the policy and procedure had been further developed to be more service user accessible. The manager demonstrated a good working knowledge of Adult Protection issues and No Secrets, the strategy for the abuse awareness and was able to show the actions to be taken if an incident occurred. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 13 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, 25, 27 and 30 The home provides suitable accommodation for the service user group but is in need of improvements to the interior and to the bathing and toilet facilities to further meet the assessed need of the service users. EVIDENCE: The home provides pleasant accommodation in a large house in its own expansive gardens that could be reorganised to provide areas of interest to service users. The home is approached from an unlit lane from the main road and it was recommended at the last inspection that this should be installed with lighting. There were a number of areas in the home that required redecoration and a radiator cover in the lounge was loose and damaged. It was also noted that the stair carpet was loose in places and needed securing. The manager discussed plans to enlarge the kitchen and dining area and it was hoped this would be completed soon as there was limited space for service users and staff to dine together. It was noted that there was a rope swing in the garden that had been to a tree branch. The manager said a risk assessment had been conducted for its use but it was advised that a Health and Safety Officer be contacted. It was also noted that a green house in the Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 14 garden was well used by a service user. On examination it was seen that a number of glass panels were broken and sharp glass fragments were left in place. It was advised that the broken glass be removed and the glass panels replaced with toughened glass. Service users bedrooms had been furnished and decorated to the service users taste and choice and were satisfactory although there were some signs of wear and tear. One bedroom was quite dark due to trees growing nearby and blocking out the light The manager said that there was to be extensive refurbishment of the bathroom and toilet facilities in the following year. It was noted that the flooring in a bathroom needed to be replaced and water temperatures had been recorded and found to be consistently under the recommended 43 degrees centigrade. The manager said that arrangements had been made to check on the boiler function. An extractor fan in a bathroom was not working due to a tree branch poking in from the outside. This required snipping off and removing to reinstate the fan. The home was generally clean, tidy and free from odour. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 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) 34 and 35 Staff recruitment is carried out satisfactorily and training is constantly updated and developing. There is a commitment to provide staff with the knowledge to meet service users assessed needs. EVIDENCE: Examination of staff files found them to be satisfactory and followed the recommended guidance on recruitment and selection of staff. Training at the home was continuing and the Learning Disability Awareness Foundation (LDAF) course had been undertaken by a number of staff. The staff training plan showed courses in Epilepsy Awareness and Autism was also provided and studies leading to the achievement of at least NVQ2 in care were completed and some staff members were continuing to NVQ level 3 in care. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 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) 38 and 42 The registered manager uses skills and abilities to provide a good standard of care to service users and to ensure health and safety within the home. EVIDENCE: The manager has the NVQ4 in care and has completed the Registered Managers Award. In addition the manager is able to offer specialist advice and training in the area of behaviour management but currently has only 10 hours per week designated to the management of the home. Records of maintenance and fire safety were held at the home and were found to be satisfactory. The manager demonstrated that as far as reasonably practicable the health, safety and welfare of service users, staff and visitors to the home, were maintained. Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 17 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 3 3 x 3 x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 x 3 x x 3 Standard No 11 12 13 14 15 16 17 x x x 3 x x 3 Standard No 31 32 33 34 35 36 Score x x x 3 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Belchford Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x 3 x x x 3 x B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 24 Regulation 23 Requirement An assessment must be made of the safety of the entrance road to the grounds, particularly for staff using this alone and in the dark. The registered person must seek the advice of a Health and Safety Officer about the use and construction of the garden swing. The registered person must remove the broken glass from the greenhouse area and make suitable arrangements for replacement glass to be fitted. Timescale for action 31 October 2005 2. 24 13 1st October 2005 3. 24 13 1st October 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 24 Good Practice Recommendations The manager should make arrangements for redecoration to be carried out where needed, stair carpet to be secured, hot water temperatures to be within acceptable limits, and the extractor fan to be re-instated. The manager should ensure that plans to improved the kitchen/ dining area and the batrhrooms are carried out. B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 19 2. Belchford 24 Belchford B54 S7457 Belchford V228591 100805 Stage 4.doc Version 1.30 Page 20 Commission for Social Care Inspection No 1. Hopetown Studios Brinkburn Road Darlington DL3 6DS 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. 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