CARE HOME ADULTS 18-65
Bellamys Cottage Sleight Centre Weelsby Road Grimsby North East Lincs DN32 9RU Lead Inspector
Christina Bettison Unannounced Inspection 5th January 2006 10.00 Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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 Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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. Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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) Linkage Community Trust Mrs Jean Bristo Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 1st August 2005 Brief Description of the Service: Bellamys Cottage is a care home providing personal care and accommodation for up to six 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 six-bedroom bungalow that is set in extensive and 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. Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection of Bellamy’s cottage was unannounced and was carried out over 2 hours. Two members of staff, the registered manager and all of the service users were spoken to. Interactions were observed during the inspection. This report should be read in conjunction with the report of the inspection carried out on the 1/8/05 as the majority of core standards were assessed at that inspection and all were met or exceeded the standard. No requirements were made at either the previous inspection or this one. What the service does well: 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
Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 6 contacting your local CSCI office. Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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 Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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): EVIDENCE: NMS 2 and 4 were exceeded at the previous inspection therefore none of these standards were assessed at this inspection. Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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): EVIDENCE: NMS 6,7 and 9 were met at the previous inspection therefore none of these standards were assessed at this inspection. Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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): 12,13,15,16,17 Service users are assisted to continue their personal development and have access to the community for a wide range of leisure pursuits. Family contact is maintained and all service users enjoy a healthy diet. EVIDENCE: The inspector was informed that none of the service users currently access any work placements, however they do engage in a wide range of activities to continue their opportunities for personal development. Emphasis is placed on service users taking an active role in household chores and 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 drama, IT, art, communication skills and horticulture. The sessions are tailored to individual need, which is assessed by the instructors. Some service users attend the day
Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 11 services provided by the local authority at Queen St day centre and some attend the Grimsby Institution and the Nunsthorpe/Bradley Adult education centre for literacy skills. Bellamys cottage is situated in the grounds of the Linkage college campus and therefore the service users do not have any neighbours. The inspector was informed that service users enjoy going to swimming, shopping, disco’s, walks and out to the local pubs. The manager confirmed that they have an open door policy for relatives and they are welcome to visit at any time. They all recently attended the Christmas party. The manager and staff promote a healthy eating menu but try to balance this with service users likes/dislikes and special treats on occasions. Breakfast consists of a variety of cereals, crumpets, toast, tea, coffee and juice. Lunch is a choice of sandwiches, soup, toasted sandwiches, beans or egg on toast or omelette. Options on the menu for dinner included chicken, mince, pizza, pasta, fish, all served with fresh vegetables and the manager confirmed that there is always plenty of fresh fruit and yogurts available. Any restrictions are clearly documented in the care plan and agreed to by the service user. Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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): 20 Service users are protected by robust medication policies and procedures; record keeping and safe storage and training for staff. EVIDENCE: NMS 18 and 19 were exceeded at the previous inspection therefore they were not assessed at this inspection. Linkage has robust medication policies and procedures that include receipt, storage, administration and disposal of medication. The GP regularly reviews service users medication and the local pharmacist regular reviews the systems. The medication systems were examined by the inspector as part of the inspection process and found to be well managed and robust. All staff are given medication administration induction training, which includes a competency check. One of the service users at Bellamys cottage was prescribed controlled drugs at the time of this inspection. The medication was stored in the controlled drugs cabinet and records maintained in the controlled drugs register.
Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 13 Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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): EVIDENCE: NMS 22 was exceeded and NMS 23 was met at the previous inspection therefore these standards were not assessed at this inspection Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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): EVIDENCE: All of the NMS were met or exceeded at the previous inspection therefore they were not assessed at this inspection. Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 16 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): 32,34 Staffing is provided in sufficient numbers and with the competence and qualities to meet service users needs. A robust recruitment and selection process protects service users from the risk of harm. EVIDENCE: NMS 35 was exceeded at the previous inspection therefore it was not assessed at this inspection. Staffing is provided in sufficient numbers and staff have the competence and qualities to meet service users needs. From examination of staff files it was evident that all staff have clearly defined job descriptions and are clear about their role and how this fits in with the linkage aims and meeting service users needs. 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 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.
Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 17 There had been two new staff employed at Bellamy,s cottage since the previous inspection, from examination of the staff files it was evident that Linkage recruitment policies and procedures continue to be robust and that all staff have CRB disclosures, all identity as required by regulation and references obtained prior to commencement in employment at Linkage. Staff are subject to a 6 month probationary period following appointment and a detailed induction programme is undertaken. Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 18 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): 37,39 Linkage is a creditable organisation that is well run and managed from the top down and the service at Bellamy,s cottage 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: NMS 42 was met at the previous inspection; therefore it was not assessed at this inspection. 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.
Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 19 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 and this is reflected in the positive inspections that have been carried out. Linkage have a Corporate Quality Monitoring system (EFQM) and a College 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 Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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 Standard No Score 1 x 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 x 23 x ENVIRONMENT Standard No Score 24 x 25 x 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 4 33 x 34 4 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score x x x x x LIFESTYLES Standard No Score 11 x 12 4 13 4 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 x 4 x 4 x x x x Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 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. Standard Regulation Requirement Timescale for action 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 Bellamys Cottage DS0000002825.V275817.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor 3 Hesslewood Country Office Park Ferriby Road Hessle HU13 0QF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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