Inspection on 31/01/06 for Belchford

This inspection was carried out on 31st January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Belchford 24/05/07

Belchford 24/05/06

Belchford 10/08/05

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 Belchford Hesleden Road Hesleden, Blackhall Hartlepool TS27 4PB Lead Inspector Stephen Willcock Unannounced Inspection 31st January 2006 11:00 Belchford DS0000007457.V269550.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 Belchford DS0000007457.V269550.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. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Belchford Address Belchford Hesleden Road Hesleden, Blackhall Hartlepool TS27 4PB 01429 836286 01429 836286 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) londonroad@tiscali.co.uk Milbury Care Services Limited Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th August 2005 Brief Description of the Service: Belchford provides residential 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. The Milbury organisation has recently become part of the Paragon Group. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on the 31st January 2006 and lasted around 4 hours. Time was spent talking to service users, 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 she is awaiting registration with the Commission for Social Care Inspection. The home was very pleasant, although in need of some redecoration, and the service users who were at the home on the day appeared happy and well cared for. The introduction of Person Centred Planning has been positively implemented in the home. Plans for the refurbishing of the home had been made but not yet carried out, but some areas highlighted at the last inspection had been attended to promptly. Staff training was on going and studies leading to qualifications at NVQ level 2 and 3 were being undertaken. What the service does well: The home continues to provide a peaceful environment where service users can choose to be in company or enjoy being by themselves in the garden areas. The new manager has been able to quickly understand service users who display many elements of complex needs and behaviours and can bring her previous knowledge and experience to the role. There were many areas that had been developed within the care planning and service users personal information files including individual communication methods. Links with social care and health care professionals were fully maintained. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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 DS0000007457.V269550.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 5 The home can demonstrate how it can meet the service users needs and provides a statement of terms and conditions or contract. EVIDENCE: The home produces a Service Users Guide giving detail of the services provided. Service users files were seen to be accurately documented and contained individual needs within a care plan. Regular review of the plan ensured that changes in need were acted upon. Pre admission assessments were made available and identified how the home would be able to meet the service users identified needs. Service agreements were in place for each service user and took the form of a statement of terms and conditions or contract. Individual service user contracts had been signed by the service user or a family representative, social worker or advocate. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 Service users are assisted to make life choices. EVIDENCE: Evidence was available to show that staff involved service users in making decisions about their lives through understanding of likes and dislikes and needs. Some service users at the home had speech impairments and staff had learned, through observation of behaviour and gesture, what the service user required. Person centred planning had been introduced into care plans and included a list of individual behaviours to assist staff in communication. Service users had been enabled in this way to express their wishes especially in buying items for entertainment, outings and choosing holiday destinations. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 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 the following standard(s): 12, 13, 15 and 16 Service users have varied activities and are encouraged to be part of the local community, maintaining contact with family and being responsible for their daily lives. EVIDENCE: Activities at the home are wide and varied and service users participate in a group or individually. Due to the nature of disability, service users were not using local colleges or day centres and staff had found activities such as hydrotherapy, horse riding and soft play beneficial to the service users. Social activities at a local pub were frequently attended where service users met with residents from other homes in the area. A time table of activities had been prepared and also included domestic tasks to be done around the house. The home has the use of a vehicle to access the local community and this is used on a daily basis for shopping trips to nearby Blackhall, and to Hartlepool and further. Contact with family and friends, was maintained and regular. Staff encouraged visits by family and arranged transport when needed. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 11 Service users are encouraged by staff to carry out domestic tasks and to assist with their own laundry and personal care. Staff were seen to carry out their roles in a dignified and respectful manner, maintaining a good rapport with each service user. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 and 19 Service users preferred way of receiving care is respected and health and emotional needs are met. EVIDENCE: Details of the personal support that each service user needs are recorded in the care plans and staff have full knowledge of service users preferred way of giving their care and by whom. Service users with impaired verbal communication skills are fully understood by staff that have developed an understanding of their needs through eye contact and body language. Person Centred Planning has been developed with each service user and families have been invited to take part in the process. Service users received regular health checks from their own doctor and there is good involvement with community nursing staff and specialist services such dieticians, chiropody and opticians. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were assessed at the last inspection. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 and 28 The home offers comfortable surroundings for service users and improvements to the environment are in hand. EVIDENCE: Service users bedrooms were personalised to their individual choices and tastes. However one service users bedroom was in need of attention as the carpet showed signs of wear and some repainting was needed. Plans for redeveloping the home have been put forward to include the enlargement of the kitchen and dining areas, and for redecoration of the home. Some areas needed urgent attention especially in a toilet where the toilet seat was missing. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 Staff at the home are competent and provide effective care to service users. EVIDENCE: The home employs 11 permanent staff and two part time staff. The majority of staff are engaged in studies leading to NVQ qualifications and four staff members have achieved NVQ2 in care and three staff members have progressed to level 3. Other training has been undertaken including courses in Moving and Handling, Food Hygiene and the Learning Disability Foundation Awareness course (LDAF). Belchford DS0000007457.V269550.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 and 39 The home is well run, in the best interests of service users. EVIDENCE: The new manager demonstrated forward thinking and planning in the care provided at the home and was able to access up to date information currently available from many other sources. The manager has recently taken up the post and was previously registered as a manager of a domiciliary care agency. The manager also had previous experience within the area of Learning Disability and has completed NVQ4 in management and the Registered Managers Award. In addition to these qualifications, the manager needs to complete the NVQ4 in care. Quality Assurance monitoring is carried out at the home in the form of questionnaires to service users families and healthcare professionals involved in the service users care. The results of surveys and information about the services are published in the organisations magazine the “Milbury Kite”. Monthly audits are also carried out to comply with the Care Homes Regulations. The manager said that frequent meetings are held with relatives to appraise and review the care provided at the home. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 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 X X 3 X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X 2 X 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Belchford Score 3 3 X X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X X X DS0000007457.V269550.R01.S.doc Version 5.0 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 YA24 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. Timescale for action 31/10/05 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 2 3 4 Refer to Standard YA26 YA28 YA32 YA37 Good Practice Recommendations The manager should make arrangements for the replacement of a carpet in a service users bedroom and for redecoration. The manager should arrange for the refitting of the toilet seat. The manager should ensure that at least 50 of staff achieves NVQ2 in care. The manager should achieve NVQ4 in care. Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Darlington Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Belchford DS0000007457.V269550.R01.S.doc Version 5.0 Page 20 - 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!