Inspection on 01/05/07 for Bellamys Cottage

This inspection was carried out on 1st May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bellamys Cottage 05/01/06

Bellamys Cottage 01/08/05

Bellamys Cottage 23/07/04

Bellamys Cottage 25/02/04

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 Bellamys Cottage Sleight Centre Weelsby Road Grimsby North East Lincs DN32 9RU Lead Inspector Christina Bettison Unannounced Inspection 1st May 2007 09:30 DS0000002825.V338102.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000002825.V338102.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000002825.V338102.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bellamys Cottage Address Sleight Centre Weelsby Road Grimsby North East Lincs DN32 9RU 01472 241893 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) www.linkage.org.uk Linkage Community Trust Mrs Jean Bristo Care Home 7 Category(ies) of Learning disability (15) registration, with number of places DS0000002825.V338102.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: Bellamys Cottage is a care home providing personal care and accommodation for up to seven adults 18-65 years of age who have a learning disability. The home is situated in Grimsby and is owned by Linkage Community Trust Care Services. The accommodation is provided in a purpose built seven bedroom bungalow that is set in private gardens within the Linkage College campus. The home is close to local transport links, parks and the resort of Cleethorpes. Bellamys Cottage shares a registered manager with another small Linkage Home situated nearby on Abbey Drive. DS0000002825.V338102.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was a key inspection and the unannounced site visit took place over 1 day on 1st May 2007. Three relatives’ surveys were returned, seven service user surveys were returned, (service users were assisted by staff to complete these), one health and social care professional survey was returned, and five staff surveys were returned. The registered manager and one of the houseparents were spoken to on the day of inspection. Observations of care practices were undertaken to check if service users were receiving appropriate care to meet their needs. The inspector looked around the home and looked at records. Information received by the CSCI since the previous inspection was also considered in forming a judgement. Prior to the visit the inspector referred to complaints received and notifications sent to the Commission for Social Care Inspection, the event history for the home over the past year and the completed pre- inspection questionnaire. The site visit was led by Regulation Inspector Mrs.C.Bettison and the visit lasted six hours. Weekly fees are £620.00 to £845.97 per person per week. Additional charges are made for the following: newspapers/magazines and sweets, hairdressing, chiropody and transport for social activities. Information on the service is made available to current service users via the statement of purpose, service user guide and inspection report. What the service does well: Service users and their relatives are provided with information that is easy to read so that they know what to expect from the home. New service users are able to visit the home and stay overnight to help them to decide if the home will be able to meet their needs or not. All service users have a single room that is nicely personalised to their own taste, providing them with an area where they can spend private time or receive visitors. DS0000002825.V338102.R01.S.doc Version 5.2 Page 6 Relatives are very involved in the home and are made to feel welcome, making sure that family can keep in contact. The kitchens are kept clean and service users are helped to eat a healthy diet. Each service user now has a health action plan which helps to make sure that their health needs are met. Service users medicines are looked after well and staff assist service users to take their medicines safely. Service users and their relatives concerns are listened to and staff make sure they take action to sort problems out quickly. The staff and managers know that they need to make sure service users are protected from harm and what to do if someone is harmed. A good recruitment policy is in place so that staff employed are safe to work with the service users and they are protected from harm. The staff are very caring and treat service users with respect and dignity. At least half of the staff have got a certificate (NVQ Level 2) which says they know how to work with the service users in the home and how to meet their needs. The registered manager is qualified and competent to fulfil her role as the manager. What has improved since the last inspection? What they could do better: Each service user needs to have a detailed service user plan to make sure they get the care and support they need. If service users are stopped from doing something to protect them from being hurt or hurting others or because it is better for them to eat certain foods this must be agreed by them, their relatives and other interested people and must only be in their best interests. Service users need to be able to make choices about some of the foods they eat. DS0000002825.V338102.R01.S.doc Version 5.2 Page 7 Some of the paperwork needs to be tidied up so that it is clear to see that service users personal and health needs are being met. Service users need to be supported to attend leisure activities of their choice, staff need to be provided to support this. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. DS0000002825.V338102.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection DS0000002825.V338102.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 4 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users needs are assessed in full by a range of professionals and service users and their families are given sufficient information about the home so that they can be assured that the home can meet their needs. EVIDENCE: DS0000002825.V338102.R01.S.doc Version 5.2 Page 10 The home has a statement of purpose and this details all of the information required by this standard and Schedule 1 of the Care Homes Regulations 2001 for adults 18-65 years. A number of appendices have been attached covering key policies such as Adult Protection, Whistle Blowing and Confidentiality. This had also been produced in an audio format. A service user guide is available and this contains all the information required by National Minimum Standard 1.2. The service user guide had been expanded to also meet the requirements of a statement of terms and conditions for service users. The care files of two service users were examined, one of these being a new admission to the home. This contained a range of assessments carried out by a variety of professionals who hade been involved in the care of the service user in previous care settings. In addition to this the manager undertakes a linkage assessment and Linkage employs a professional support team made up of qualified social workers, psychiatrist, clinical psychologist, speech and language therapist, visual impairment specialist and a registered nurse who can support the ongoing assessment process and provision of professional support. The staff team had more than enough information on the assessed needs of the service user and this enabled them to provide an individually tailored service to meet the service users complex needs and ensure their emotional stability. There was evidence that they had been offered and had taken up the opportunity of visits and overnight stays prior to making a choice about living at the home. In addition to this there was evidence that the other service users in the house had been consulted about the new service user moving in and had agreed to it. Despite an unsettled start the staff have managed this placement admirably and the service user has now settled in well. The new service users stated in the returned survey “when he saw the house he liked his room and the home and couldn’t wait to move into his new home” he also stated that “he chose most of his furniture, bedding curtains and the carpet”. DS0000002825.V338102.R01.S.doc Version 5.2 Page 11 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 and 10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users needs are generally met and service users and their representatives have been consulted, however the quality and consistency of the service user plans and risk assessment needs to be improved. EVIDENCE: Two care Files were examined as part of the inspection process. Each file contained a focus page which gave staff a quick overview of a service users needs, dietary requirements, information on advocacy services and a personal history and signposted towards behaviour management guidelines and risk assessments. Although all of the assessment information was available to ensure that all of the service users assessed needs were identified and met, the care planning DS0000002825.V338102.R01.S.doc Version 5.2 Page 12 process and paperwork was a little disjointed and contained far too may risk assessments. A number of the risk assessments were actually plans of care and the home would benefit for re organising the plans and risk assessments. In one of the care files examined the care plan was quite basic and did not include any detail of cultural and religious needs. Care plans required further detail on exactly what support staff needed to provide for service users and an element of what skills and ability service users already have in order to build on these and demonstrate progress. This is especially important at Bellamy,s cottage as the service users that live here have more complex needs and need a lot of staff support. This service user likes to eats sandwiches and would eat them for every meal, however the management and staff are not allowing him to do this. Clearly this has been arranged for the service users benefit however it is a limitation to his basic rights to choose what he eats and must be discussed and agreed at a multi agency meeting where all parties agree that it is in his best interests and a written record kept. He has also lost over a stone in weight in the past year, although this is of positive benefit there needs to be a detailed care plan devised to guide staff on diet, nutrition and what would be the ideal weight for the service user to reach, all of this must be in agreement with the service users and relevant parties. In this care file there were only risk assessments not care plans for medication, finance and diet and nutrition. This service users had only had a 12 week initial review and no other review since and the homes internal monthly monitoring system was ineffective and did not pick up where Person Centred planning goals had not been met and did not review the Person Centred plan. In another care file examined again the care plan was very basic, i.e. for personal care it only stated, “staff support and guidance needed with all aspects” this does not give staff enough guidance in how to meet service needs. In addition to this other care plan areas i.e. communication, and independent living where very basic and some risk assessments i.e. finance and diet and nutrition should have been care plans. This particular service users has some behaviours towards vulnerable people whilst in the community that can be difficult to manage, however there was no care plan or behaviour management guidelines for staff in this area. This service user also had a person centred plan that was dated July 2002 and had not been reviewed or amended since then. DS0000002825.V338102.R01.S.doc Version 5.2 Page 13 In addition the internal monitoring systems were ineffective and failed to identify where goals had not been met or effectively update care plans and PC Plans. I.e. there was a statement in the focus page to say that due to inappropriate behaviour one of the service users had been stopped from attending the day service, however from the daily records it was clear that he had started attending again. This page had a review date and a signature on the bottom of the page to say that it had just been reviewed however this element had not been amended. However feedback from professionals and discussion with service users evidenced that service users and relatives were happy with the service and that there needs were met and independence promoted in many ways. Service users physical and emotional well being was recognised and met by staff however the service users that live at Bellamys cottage have complex needs and require a lot of staff support. In addition to this some of the service users had benefited from a person centred plan meeting, actions from these plans need to be met, kept under review and incorporated into the care planning process making it more comprehensive and cohesive. A number of risks had been identified, assessed and were being minimised by the production of risk assessments that staff were familiar with and followed and a number of these related to measured risk taking allowing service users to develop and maintain their independence. All service users had a key worker and were able to tell the inspector who this was and explain what their specific role was. The inspector observed service users being offered opportunities to participate in the day to day running of their own home; they have house meetings once a week and all service users have a house day when they change their bed, clean their room and do their laundry, with as much or as little support as is required by the individual. Staff and service users confidential information was observed to be securely kept and handled in accordance with the Data Protection Act. Lockable facilities were used and service users are consulted about when and where there information can be shared. Staff were observed to knock on doors and to ask permissions to enter bedrooms. Linkage has a policy on sharing information with partner agencies and a policy/procedure for missing service users. DS0000002825.V338102.R01.S.doc Version 5.2 Page 14 DS0000002825.V338102.R01.S.doc Version 5.2 Page 15 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,and 17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are assisted to continue their personal development however access to leisure pursuits of their choice is limited and needs to be improved. This could be further enhanced by the maintaining and flexibility of the staff rotas and attention to individual’s personal aspirations. Family contact and personal relationships are maintained and all service users enjoy a healthy diet. EVIDENCE: Service users at Bellamy,s Cottage have significant needs and all require a moderate level of support from the staff team. Therefore none of the service users have work placements. DS0000002825.V338102.R01.S.doc Version 5.2 Page 16 Service users are encouraged to develop their independence skills and to take an active role in household chores, they all have at least one day at home to change their beds, clean their rooms and do their laundry with staff support as required. Some service users attend the Linkage occupational recreational services during the day and take part in activities such as Advocacy groups, drama, ITC, art, communication skills and horticulture. The sessions are tailored to individual need, which is assessed by the instructors. In one of the care files examined it identified in the Person Centred Plan dated 31/7/02 that the service user liked watching trains, going out for meals, likes to visit the Grimsby auditorium for shows and the pantomime, however the daily records evidenced that from January 2007 he had been out for car drives, to the shops, to the pub and for walks in the grounds. In another care file examined the Person Centred Plan dated 6/6/06 identified that the service user liked to visit historical buildings, parks, shops and pubs, visiting his mum, swimming, indoor bowling and watching the airplanes take off at the airport. However the daily records only evidenced walks around the grounds, visits to the local shops and attending quayside day services for art, advocacy and ICT. Neither of the Person Centred Plans had been reviewed since they were devised. This does not ensure that service users diverse needs and person centred plan goals can be met and this must be given more attention. Staff commented that they are not always able to support service users to undertake individual activities because of the staffing numbers and rota. The staffing hours provided needs to be reviewed to ensure all of the service users needs can be met. The manager and staff promote a healthy eating menu. Breakfast is cereals and toast. Lunch is either provided at the day services or is a choice of sandwiches. Options on the menu for dinner included chicken, spaghetti bolognese, sausages, pasta, fish/fish cakes, curry, the menu appeared a little repetitive and the lunch on the day of inspection was one round of sandwiches and yogurt or fruit. The service users have complied with the healthy eating plan however some staff commented that the promotion of healthy eating limited service users right to choice of snacks etc. Any restrictions regarding meals and/or lack of choice need to be clearly documented in the care plan and agreed to by the service user and their representatives. Due to health needs, weight issues and general well being the home promotes a healthy eating menu however on their house days service users usually go DS0000002825.V338102.R01.S.doc Version 5.2 Page 17 out shopping and can buy whatever they want to, in addition to this when they are out alone, at day services or visiting family they can buy and eat whatever they choose and on special occasions I.e. birthdays, Christmas etc special treats and buffets are provided. It was felt that the balance was right for the service users and ensures their physical well being and ongoing good health. DS0000002825.V338102.R01.S.doc Version 5.2 Page 18 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users physical and emotional needs are met, by the provision of a wide range of healthcare professionals and outside agencies and a caring and professional team of staff promotes their privacy, dignity and respect. EVIDENCE: Records examined confirmed that service users health needs were met by GP, dentist, chiropody and that they had access to a wide range of other health professionals e.g. psychiatrist and psychologist, speech and language therapist and visual impairment specialist if and when required. However there needs to be some improvement in the screening, identification and planning to meet health needs. Health action plans had been produced but these were basic and had not been regularly updated. In addition to this the recording of outcomes to health appointments were in the general daily DS0000002825.V338102.R01.S.doc Version 5.2 Page 19 recordings and did not sit alongside the health action plan, this could made it difficult to track if health needs had been met or not. Discussion with Service users and staff and observations confirmed that the staff promoted service users dignity, privacy and respect. Staff were observed to behave in an appropriate manner towards service users. A relative commented “The care at Bellamys cottage is excellent and a lovely home for all patients. Jeannie makes the best decisions about health care and keeps me informed on my relatives health, progress etc”. Linkage has robust medication policies and procedures that include receipt, storage, administration and disposal of medication. Most of the service users at the Limes are self medicating are encouraged to work toward this with a graduating self-medication programme which is supervised by the staff. The manager and staff will assess the service user prior to commencement and a risk assessment is undertaken. Facilities are made available for service users to lock their medication away in their room. All staff are given medication administration training which includes an exam to ascertain competence. DS0000002825.V338102.R01.S.doc Version 5.2 Page 20 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users are protected from harm by a robust complaints procedure that is provided in an accessible format and all service users are aware of and a Protection of Vulnerable Adults policy and procedure that the staff and manager are aware of their responsibilities within this. EVIDENCE: DS0000002825.V338102.R01.S.doc Version 5.2 Page 21 The home had a well-developed complaints procedure. This contained contact details for the CSCI and the ombudsman and gave an assurance that service users and their families would not be victimised for making a complaint. The timescale given for responding to complaints was 21 days. The complaints procedure was also available in Makaton symbols and on audiocassette. In addition to the above the home also had a service user specific complaints policy. All of the surveys received back from service users indicated that the service users knew who to go to if they had a complaint or concern. Each service user had been given a copy of the complaints policies in written and Makaton format, and Social Services “Right to Complain” leaflet. These were kept in service users individual files. All minor issues were dealt with through the house meetings. More serious issues were taken to the manager and a mechanism is in place for responding to these areas of concern and/or complaint. There had been a small number of complaints since the previous inspection; the majority of these were issues of service user going into each other’s rooms. This has been resolved by the provision of locks and alarms. All complaints had been taken seriously, investigated and resolved appropriately. The manager checked the complaints log on a regular basis. The home had a copy of the “Multi agency Guidelines for the Protection of Vulnerable Adults” and an in house abuse policy and procedure that links in with the “Multi agency Guidelines for the Protection of Vulnerable Adults” in respect of alerting, referral and investigation. All service users had been given a copy of the leaflet from the local authority on abuse and this was kept on their individual file. The home has a separate whistle blowing procedure. There was evidence from the home’s recruitment and selection processes, staff training records, complaints log and the use of risk assessments that the manager ensured that service users were protected and safeguarded from abuse. Training records evidenced that staff had received training on the protection of vulnerable adults and the staff spoken to were clear about their responsibilities within the POVA procedures. DS0000002825.V338102.R01.S.doc Version 5.2 Page 22 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users live in a well maintained home that is safe, homely and comfortable and is in the heart of the local community and meets their assessed needs. EVIDENCE: Bellamy,s cottage is situated in Grimsby and is owned by Linkage Community Trust Care Services. The accommodation is provided in a purpose built seven bedroom bungalow that is set in private gardens within the Linkage College campus. The home is close to local transport links, parks and the resort of Cleethorpes. DS0000002825.V338102.R01.S.doc Version 5.2 Page 23 All fixtures/fittings and furniture are of a very good quality and on the day of inspection the house was extremely clean and tidy and very well presented. There is also an office, and staff sleeping in room. The house is very spacious enabling service users to spend time with each other or alone as they choose. Outside is a drive and pleasant gardens. DS0000002825.V338102.R01.S.doc Version 5.2 Page 24 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staffing is provided with the competence and qualities to meet service users needs, however some service users are not able to participate in activities of their choice due to the staffing arrangements. A robust recruitment and selection process protects service users from the risk of harm. EVIDENCE: There have been no changes to the rota pattern however there has been an increase in the numbers of staff due to an increase in the numbers of service users to seven and there are usually two full time staff and a part time staff on duty. DS0000002825.V338102.R01.S.doc Version 5.2 Page 25 The current staff rota provides waking staff up to 11.00pm and after that they sleep in. This does create some difficulties if service users wish to access activities that finish after 11.00pm. In addition to this as detailed in the lifestyle section of the report some of the service users diverse leisure needs are not being met, this maybe due to restrictions in staffing numbers and the rota therefore Linkage need to review the staffing rotas and ensure that staff can be provided in a flexible manner to support service users diverse needs and expressed wishes. A staff member commented in a survey “There have been many occasions throughout the year when we have been very short staffed and due to this we have been unable to spend much time with the service users. Going out on leisure and to do their personal shopping has been a quick visit to the supermarket for the homes shopping and the service user and pressure on staff to return quickly. A Great room for improvement would be for the allocated hours at Bellamys to be filled and the part time workers not moved to Abbey drive, they should have their own part time staff to cover off duties etc”. Observation of staff practices confirmed that they have developed appropriate relationships with service users and treat them in an age appropriate way and with the utmost of dignity and respect whilst offering guidance and support in a firm but sensitive manner. The staff team are supported by a wide range of health professionals e.g. psychiatrist and psychologist, speech and language therapist and visual impairment specialist for advice and support. A relatives commented, “I am very grateful for the high level of care and comfort provided for my brother and cannot praise the staff too highly. His individual needs are always considered and catered for”. A new member of staff (cleaner) file was examined as part of the site visit and this evidenced that Linkage recruitment policies and procedures continue to be robust and staff have CRB disclosures, all identity as required by regulation and references obtained prior to commencement in employment at Linkage. Supervision records were examined and were in order and the current staff team are up to date with their mandatory training and have undertaken other specialised training relevant to the needs of the service users, i.e. epilepsy, autism, managing difficult behaviours, downs syndrome and risk assessment training. The new member of staff had completed his probationary period. The registered manager had a training and development plan for the staff team that clearly identified staff training needs and all staff had an individual training and development action plan that was completed annually. DS0000002825.V338102.R01.S.doc Version 5.2 Page 26 The home has seven staff of these, 1 member of staff has achieved NVQ level 3, 3 have achieved NVQ level 2 in care and the new member of staff (cleaner) has got NVQ level 1 in cleaning and housekeeping. DS0000002825.V338102.R01.S.doc Version 5.2 Page 27 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users benefit from living in a home that is part of a creditable organisation that is well run and managed from the top down and the service at Abbey drive is managed by a very competent manager. Service users are at the heart of the organisation and their views are taken into account by the quality monitoring scheme, house meetings and reviews that promote their involvement. EVIDENCE: DS0000002825.V338102.R01.S.doc Version 5.2 Page 28 Mrs Jean Bristo is the registered manager at Bellamy’s Cottage and its’ sister home 22 Abbey Drive West. She has been the manager there since February 2002. Prior to this Mrs Bristo had been the deputy manager at Bellamy’s Cottage. Mrs Bristo has her NVQ 4 in care and management and many years experience of working with adults who have a learning disability. Regular house meetings that include staff and service users, staff supervision and the key worker system ensure that staff and service users have the opportunity to influence the way the service is delivered. Mrs Bristo is a very effective manager. Linkage have a Corporate Quality Monitoring system (EFQM) and a Quality Manager who co ordinates and leads on quality issues. A year long calendar is produced that provides the framework for QA activity including surveys, audits and appraisals. Service user comment cards had been translated into makaton symbols to aid students understanding and enable them to participate in the process. Linkage produces an Annual Review document and regular newsletters. All of which were seen by the inspector. Areas for improvement in the forthcoming year are to increase the numbers of staff across the organisation that have NVQ level 2, to roll out person centred planning, to further promote self advocacy, to purchase a holiday home for linkage and to ensure all staff have basic IT skills. As part of the inspection all maintenance records were seen and were up to date and in order ensuring that the service users live in safe environment. DS0000002825.V338102.R01.S.doc Version 5.2 Page 29 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 4 2 4 3 x 4 4 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 x 26 x 27 x 28 x 29 x 30 4 STAFFING Standard No Score 31 x 32 4 33 3 34 4 35 4 36 4 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 x 3 4 LIFESTYLES Standard No Score 11 x 12 4 13 4 14 2 15 4 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 4 x 4 x 4 x x 4 x DS0000002825.V338102.R01.S.doc Version 5.2 Page 30 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 YA6 Regulation 15 Requirement Timescale for action 31/08/07 2 YA7 12 3 YA14 16 2(m) The registered person must review and amend the care planning process/paperwork to ensure its effectiveness and care plans should be produced in a format that is accessible to the service users. The registered person must 31/08/07 ensure that where any limitations on choice are made are only made in the persons best interests and in consultation with relevant parties. The registered person must 31/08/07 ensure that service users are able to access leisure activities of their choice and that staff is provided to support this. 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 YA9 Good Practice Recommendations The registered person should review the quantity of risk DS0000002825.V338102.R01.S.doc Version 5.2 Page 31 2 YA17 3 YA33 YA19 YA19 assessments and ensure that they relate to identified risk areas and not areas where service users require support to live an independent lifestyle. The registered person should provide evidence that service users choices and wishes in relation to food are identified and adhered to and any reasons why not documented in a best of interest meeting. The registered person should review the staffing numbers and deployment to ensure that all of the service users diverse needs can be met. The registered person should review and amend the health action plans and recording methods to ensure that they are kept up to date and are effective. 4 DS0000002825.V338102.R01.S.doc Version 5.2 Page 32 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000002825.V338102.R01.S.doc Version 5.2 Page 33 - 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!