Inspection on 25/04/07 for Besford House

This inspection was carried out on 25th April 2007.

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 12 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Besford House 10/06/08

Besford House 22/05/06

Besford House 27/01/06

Besford House 23/09/05

Besford House 08/12/04

Besford House 03/04/04

Besford House 27/09/03

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

CARE HOME ADULTS 18-65 Besford House 19 Besford Road Liverpool L25 2XT Lead Inspector Beate Roth Key Unannounced Inspection 25th April 2007 09:10 Besford House DS0000035859.V332016.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 Besford House DS0000035859.V332016.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. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Besford House Address 19 Besford Road Liverpool L25 2XT 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) 0151 498 4281 www.liverpool.gov.uk Liverpool City Council Ms Sarah Jones Care Home 18 Category(ies) of Learning disability (18) registration, with number of places Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The service should at all times employ a suitably qualified and experienced manager who is registered with the National Care Standards Commission. The matters detailed in the attached schedule of requirements must be completed in the stated timescales. A maximum of 18 younger person with a learning disability is accommodated at the care home. 23rd January 2007 Date of last inspection Brief Description of the Service: Besford House is owned and run by Liverpool Social Services. The home provides support and personal care to 18 younger persons who have a learning disability. The home consists of three bungalows each accommodating six residents in single bedrooms. One of the bungalows accommodates 6 permanent residents whilst the other two provide respite care and emergency care. Each bungalow has its own domestic style kitchen, laundry room, sitting room and dining room. Each bungalow has assisted baths and a walk in shower with additional aids provided as and when required. The home is situated in the Belle Vale area of Liverpool and is easily accessible by public transport and is close to shops and other community facilities, which residents are able to access. Parking is available. At the time of the inspection, the weekly cost for the service ranged from £260.40 to £289.82 for permanent residents and was £38.70 per week for residents living at the home on an emergency or respite basis. A statement of purpose, which describes the services offered at Besford House, is available for relatives and social and health care professionals to refer to. A service user guide is available for permanent residents. Service users guides for the respite and emergency bungalows are being updated. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours and is based on a visit to the home; information received about the service since the last inspection and by questionnaires completed by the manager, relatives and health professionals. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. The inspector spoke to residents and with staff and made observations of staff delivering care to the residents. What the service does well: What has improved since the last inspection? At this visit the home is working towards meeting the requirements made at the last visit to the service in January 2007. The timescales for meeting a number of these requirements has not ended. Since the last inspection a risk assessment has been made available about visitors to the service and a record is now being kept of all meals provided. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 6 Further improvements have been made to the presentation of all three bungalows. There has been an improvement to the quality assurance systems. Questionnaires, relative’s forums and a newsletter are being used to find out the views of residents and relatives. Team meetings have been held 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. The summary of this inspection report can be made available in other formats on request. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 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 Besford House DS0000035859.V332016.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process would ensure that the service is only offered to individuals whose needs can be met at the home. Some residents do not have access to information about the home that is needed to make an informed choice about whether the service is right for them. EVIDENCE: A Statement of Purpose is available showing the services and facilities offered at Besford House and a pictorial Statement of Purpose is in place to make the information more accessible to people who use the service. A review of the service user guide has taken place for the bungalow that offers permanent care and work is taking place to complete up to date service user guides that are in a suitable format for the bungalows that provide emergency and respite care. Upon completion of the service user guides for the remaining bungalows these are to be forwarded to CSCI in accordance with the regulations. There have been no permanent admissions for several years. However, the service admission procedure details that a prospective residents needs would be assessed by a suitably qualified person from the care home and that the assessment would be over a prolonged period to ensure that the service would be able to meet the residents needs. The initial assessment process covers all Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 9 of a residents’ needs including their communication, religious and cultural needs. Opportunities are available for prospective residents to make several visits for tea, overnight and weekend stays to “test drive” the service. The assessment for a resident who is living at the home on an emergency basis was seen. An appropriate assessment had been carried out that involved gaining information from the prospective resident and from their social worker. New procedures have been introduced to ensure that regular meetings take place with the resident and their social worker following an emergency placement to make sure that there are no delays in their being able to move on to a permanent home. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents can make choices and they are consulted about their lives at the home. Appropriate risk assessments are in place to ensure that residents can participate in daily activities and leisure pursuits. Further work is needed on some residents care plans to make sure staff have clear information on how to meet their needs. EVIDENCE: In the last 6 months the permanent residents have received a full community care assessment from the placing authority at the request of the registered manager to reflect their changing needs. The majority of the home’s care plans have been reviewed as a result of this. A sample of care plans seen for the permanent residents showed that the care plans were up to date and provided sufficient information for staff around the needs of the residents. Records showed that Besford House staff contact the primary carer on the day of the residents admission for respite. This is to obtain information regarding Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 11 any changes in their needs and where necessary key workers amend the care plans. A sample of three records for residents placed in an emergency were seen. These contained social work assessments from which a care plan can be developed. Work is continuing to ensure that care plans are developed with residents placed on a respite and emergency basis that set out how the residents’ needs are to be met. Residents make decisions over their daily lives such as: what activities to participate in, whether to be on their own or with others, choosing their holiday etc. Several residents were spoken with during this visit. The comments and responses to questions were positive about the experience of living at the home and of how staff support them. Residents said “ I like it here,” “it’s smashing,” “ I love it and don’t want to leave I will ask my social worker about staying,” “ staff help me when I ask,” “staff are all very pleasant and helpful.” A relative said that there are happy with the service and that person they know at the home “loves being there.” The residents are involved and made aware of changes at Besford House through residents meetings, which are generally held monthly. This provides a regular opportunity for residents to express their opinion and where necessary they are supported by the staff to do so. The records of the last residents meeting held on 25th February 2007 were seen. This showed that residents had been consulted around food, staffing, activities and were informed about how to make a complaint. The next residents’ meeting is planned for 26th April 2007. A resident spoken with said that they would not attend but would make any views they had known to a member of staff. Residents are supported to take responsible risks by engaging and accessing various community facilities independently. The service has a missing person policy, which is implemented when a residents’ absence cannot be explained. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 12 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, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Residents can engage in a good range of leisure and social activities to meet their individual needs with the support of staff as appropriate. Varied and well-balanced meals are provided in homely surroundings. EVIDENCE: The residents engage in a wide range of activities to develop new skills and to fulfil their social needs. All of the permanent residents attend a day centre where they engage in various activities such as cooking, flower arrangement and craft. Where necessary staff would support residents to access activities. The service has a range of transport options available to enable residents to access community facilities such as: Dial a Ride, taxi and staff cars. Information about community activities is brought into the service by both residents and staff, which are displayed around the bungalows. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 13 The home is a short walk from local shops, pubs, restaurants, churches and other community facilities. Other parts of the city are easily accessible by public transport, which passes outside the service. Residents are supported to maintain and develop contact with friends and family. The service has an unrestricted visiting policy and residents are able to choose where to see their visitors. Since the last visit a risk assessment has been made available where there were some concerns about a specific family. Residents’ rights to privacy are respected. Residents have a key to their bedroom. They are supported with personal care in a sensitive and appropriate manner. Residents generally have access to all parts of the building and where there are restrictions due to health and safety concerns, a risk assessment has been introduced. Although residents are not directly responsible for household tasks they are encouraged to assist care workers in keeping their bedrooms clean and tidy in accordance with their abilities. Mealtimes at Besford House are flexible to meet the residents’ needs. A record is now being kept of meals that are provided to residents. A menu is available and if a resident has something to eat that is not on the daily menu, a record is made. The menus seen showed that varied and balanced meals are provided that would meet the cultural needs of the residents. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Residents’ health needs are being met. Improvements need to be made to the home’s policies and procedures for dealing with medicines in order to fully safeguard residents. EVIDENCE: Most of the residents do not require any assistance with moving and handling and require minimal support with personal care. However, where a resident on respite requires assistance with transferring suitable specialist aids are obtained from the district nurse. The registered manager informed the inspector that she has been assured by the agency that the temporary staff supplied have current moving and handling certificates. Discussion with residents, staff and entries in the residents’ daily records show that they choose when to go to bed and they can make decisions over their daily living activities. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 15 A sample of records seen showed that residents have access to health professionals in accordance with their needs. The staff monitor the health needs of the residents and ensure that they receive regular health checks from the dentist, chiropodist, optician as well as a periodic review of their medication by their GP. Staff support residents to attend outpatient appointments in accordance with their needs. Health care records are in place for permanent residents. GP’s who returned questionnaires said that they are satisfied with the overall care provided at the home and that staff demonstrate a clear understanding of the needs of residents. Residents’ medication is held securely. An inspection of medication and records indicated that these were being given and documented appropriately. The management team administer medication and have been trained to do so. Some improvements need to be made to the records of medication that are used for some residents who stay at the home on a respite and emergency basis. At present the amount of medication to be given, dosage, time of day and any safety instructions are not recorded. This information is recorded on the container that the medication is held in. In order to ensure safe handling of medications at all times this information needs to be recorded on the medication administration record. A photograph of the resident should also be attached to each individual’s medication administration record as a further safeguard. One of the rooms where medication is stored was warm on the day of the inspection. It is recommended that a thermometer be placed in the rooms where medication is stored to ensure that medication is kept at an appropriate temperature. A risk assessment had not been recorded for a resident who looks after their medication. This assessment needs to be documented to give clear guidance to staff. Guidelines around the safe storage of oxygen and around the support a resident’ needs in using oxygen are to be made available for staff. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 16 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 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The service has various policies and procedures in place to protect residents from all forms of abuse. Improvements to the supervision arrangements for agency staff would provide further safeguards. EVIDENCE: The service has a complaints procedure, which is displayed in a prominent position. The procedure outlines how complaints would be resolved and the timescale for completing the investigation. Residents spoken with knew how to make a complaint if they are not happy with the service received. Records showed that how to make a complaint is discussed with residents at residents’ meetings. The service has various policies and procedures in place for the protection of vulnerable adults. A copy of the Liverpool City Council’s adult protection procedures is available at the home. A referral had been appropriately made to adult protection regarding a complaint made by a resident. The service uses a high percentage of agency staff to deliver care to residents. Training around adult protection is not provided by the agency who supplies the staff to the home. The manager said that during the induction process the agency staff are made aware of the adult protection procedures and that training around these procedures has been provided to the majority of agency staff. Supervision is not being provided to agency staff on a consistent basis and agency staff do not complete a comprehensive induction, therefore, the Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 17 management of the home is unable to evaluate the level of staff knowledge and understanding of these procedures. An agency member of staff and a permanent member of staff spoken with were aware of the procedure to follow to safeguard residents. The residents are supported to manage their finances with the support of staff as identified in their care plan. A record is kept of incoming and outgoings of monies. Daily checks of residents’ finances take place by the management team. The manager said that the home is audited at regular intervals by Liverpool Social Services Finance Department; however, records of this were not seen at this visit. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 18 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, 25, 27, 29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. A comfortable, safe and homely environment is provided to residents. EVIDENCE: In the last 9 months a number of works have taken place at the service to improve the home environment. The windows and doors of all bungalows have been replaced. The bungalows have been repainted and some new furniture has been provided. New flooring has been laid in the hallways and some communal areas and new blinds have been fitted to windows. The bungalows for the permanent residents were found to be particularly homely and to reflect their tastes and preferences. The bungalows are safe, comfortable and bright and all parts the bungalows and grounds are easily accessible to residents. The grounds also benefit from having a ramped area to increase accessibility. All accommodation is provided in single bedrooms and bedroom doors have suitable locks to promote residents privacy whilst maintaining their safety. Some of the permanent Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 19 residents have purchased their bedroom furniture to personalise their bedrooms. The bungalows have the required number of toilets and bathroom for the number of residents. These are located close to communal areas and residents’ bedrooms. Each bungalow has an assisted bath and a call system in residents’ bedrooms. The bungalows were all clean and tidy at the time of the visit. The domestic washing machine is in the kitchen and policies and procedures are in place to minimise the spread of infection. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 20 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): 32,33,34,35,36 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The continued reliance on agency staffing is unacceptable, as it does not provide continuity of care. The training of the majority of the care staff employed at the service does not fully meet the needs of residents. EVIDENCE: Resident’s care continues to be delivered by a large number of agency staff. 8 out of 21 staff are permanent with the remaining 13 staff being employed by an agency. The manager reported that there has been insufficient permanent staff at the home for the last 4 years. The manager has taken steps to try to minimise the effects of employing so many agency staff. An agreement has been reached with the agency used that, agency staff will work for a minimum of 16 weeks to promote continuity for the residents and the service itself. 9 of the 13 agency staff work solely at Besford House and a key worker system has been introduced to further promote continuity of care. Whilst this remains far from ideal, it is better than the previous arrangement where upon agency staff were being been booked on a week to week basis and no key worker system was in operation. The service must endeavour to rectify this unsatisfactory staffing situation and to employ permanent staff to provide continuity of care Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 21 to residents and to improve the overall quality of care provided at Besford House. Staff one to one supervision and appraisals take place with permanent staff. Supervision of agency staff who regularly work at the home has begun but needs to be consistently maintained. This is important for monitoring the performance of agency staff that are working at the care home. Since the last visit staff meetings have been held at all three bungalows. The management team had also had two meetings to discuss the operation of the service since the last visit. These meetings must now continue on a regular basis, as they are a valuable means of staff communication. All permanent staff have completed an NVQ 3 in care of adults with a learning disability. The deputy manager and two assistant managers have completed an NVQ Level 4 in care and management. The records available for the agency staff indicated that no agency staff have completed a relevant qualification in caring for adults with a learning disability. There was no evidence that agency staff had received training around meeting the needs of adults with a learning disability. An agency member of staff spoken with confirmed this. Liverpool City Council has a thorough induction programme for permanent staff. Agency staff do not have access to this induction. To ensure that all agency staff have the information they need to work at the service a brief overview of the service is given and access to written information on how the homes operate and the needs of the residents is made available. Given that over half of the staff working at the home are agency staff it is recommended that all agency staff receive a thorough induction. Records show that all agency staff have received training around health and safety, food hygiene, first aid, moving and handling and infection control, assessing risk and basic care skills. An assessment of the competence of agency staff in these areas is limited, as regular supervision is not being provided. All permanent staff have completed training around equality and diversity. These values are written in to a number of Liverpool City Council’s policies and procedures and in a number specific to the service. Agency staff are not provided with training around equality and diversity. Records show that permanent staff have access to a number of training courses. In the last 12 months some of the courses staff have attended include managing challenging behaviour, mental health awareness, race equality. Agency staff do not have access to these training courses. The inspector spoke to a permanent staff member on the day of inspection and they confirmed that were training had been offered and they were able to access it that it had been beneficial. A permanent member of staff and an agency member of staff were asked about their experience of working at the Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 22 service. They said, “I think the service is very good. I enjoy working here …every day is different and brings different challenges,” “it’s a nice place.” Both staff reported that the high number of agency staff does not benefit the residents. The records relating to the employment of agency staff were seen. Confirmation that all the relevant checks detailed in scheduled 2 of the Care Homes regulations 2001 have been carried out and details of the experience and qualifications of agency staff needs to be made available from the agency. There was evidence that agency staff have had a criminal records bureau check and that the manager is confirming their identity. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 23 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, 38, 39, 40, 42 and 43 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The views of residents and relatives influence how the service operates. The safety of residents is promoted. Residents would be more fully supported if the responsible person or their representative made regular visits to the home to make sure that the home is operating in the residents best interests. EVIDENCE: The registered manager of Besford House has many years experience of working with adults with a learning disability. Observations showed that she has good rapport with residents and staff. The manager has undertaken regular training to maintain and update her knowledge and skills. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 24 Observation and discussion with residents and staff showed that the manager is accessible and willing to incorporate the views of residents and stakeholders to improve the quality of care provided at Besford House. Since the last visit to the service the manager has organised a relatives forum. The first forum was held in February 2007. The forum suggested that a newsletter be sent out to relatives. A newsletter is currently being drawn up and the first one is to be issued in May 2007. There are other quality assurance systems in operation. Residents meetings are held every month and a record is kept of the matters discussed and what was agreed. A questionnaire was sent to relatives and residents in October 2006 and the results have been used to improve the service offered. Following a period of respite a questionnaire is sent to the residents and their relatives to identify what worked well and which areas need improvement. The views of other stakeholders such as social and healthcare professionals about the operation of the home should also be sought. The Responsible Person’s monthly visit to the home and subsequent reports are not being undertaken on a regular basis or forwarded to the Commission. This issue has been raised at previous visits to the service and must be addressed. The homes policies and procedures are developed by Social Services central policy unit and distributed to the various services. They are reviewed regularly to reflect changes in legislation and best practices. Residents records are maintained and kept in a secure place. The health and safety of residents and staff are promoted through regular checks and maintenance of the building and equipment used at the care home. The registered manager does maintain a record of all incident/accidents at the care home and the Commission is informed of significant incidents to residents and staff. There are clear lines of accountability within the home and to external management. Records are kept of all expenditure at the care home. Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 25 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 2 2 3 3 X 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 3 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 2 33 1 34 2 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 2 3 X 3 3 Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes. The timescale for a number of requirements made at the last inspection has not expired. 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 YA1 Regulation 6 Requirement The registered person must ensure that, upon completion, the service user guides for the bungalows must be forwarded to CSCI. Commenced but remains outstanding from previous inspection. (Previous timescale of 30/09/06 not met.) 2. YA6 15 The registered person must ensure that the service user plan is developed with the resident, where possible. It must set out how the residents’ needs are to be met. Commenced but remains outstanding from previous inspection 30/05/07 Timescale for action 30/05/07 Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 27 (Previous timescale of 30/09/06 not met.) 3. YA20 13 The registered persons must ensure that information around the dosage; time of day and any safety instructions, which is recorded on the container in which the medication is held, is recorded on the medication administration record. The registered persons must ensure that a risk assessment is documented where a resident is responsible for managing their own medication. The registered person must provide guidelines around the safe storage of oxygen. Guidelines around how to assist a resident who requires oxygen must also be provided. The registered person must ensure that the staff working in the care home are suitably qualified, experienced and competent to meet the health and welfare of the residents. Commenced but remains outstanding from previous inspection. (Previous timescale of 01/10/06 not met.) 7. YA33 18 The registered persons must ensure that there are sufficient permanent staff available to promote continuity of care for the residents. The registered manager must ensure that all staff files contain DS0000035859.V332016.R01.S.doc 25/04/07 4. YA20 13 25/04/07 5. YA20 13 25/04/07 6. YA32 18 30/05/07 YA23 25/07/07 8. YA34 19 30/05/07 Besford House Version 5.2 Page 28 information detailed in scheduled 2 of the Care Homes Regulations 2001. (Previous timescale of 31/07/06 not met.) 9. YA36 YA23 18 The registered manager must ensure that regular staff one to one supervision and appraisals take place and are documented in accordance with the regulations. Commenced but remains outstanding from previous inspection (Previous timescale of 30/09/06 not met.) 10. YA39 26 The Responsible Individual or 30/05/07 their representative must visit the service at least once a month and produce a report on the conduct of the home. This must be available for inspection purposes. (Previous timescale of 31/07/06 not met.) 30/05/07 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 YA20 Good Practice Recommendations It is recommended that a photograph of each resident be attached to the medication administration record sheets. DS0000035859.V332016.R01.S.doc Version 5.2 Page 29 Besford House 2. YA20 It is recommended that a thermometer be placed in the rooms where medication is stored to ensure that medication is kept at an appropriate temperature. 50 of care staff (including agency staff) are to hold an NVQ 2 or equivalent qualification. All agency staff to receive a structured induction training to ensure that they are suitably equipped to meet the needs of the residents. The views of other stakeholders such as GPs, social workers etc should be sought about the operation of the service. 3. 4. YA32 YA35 5. YA39 Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Besford House DS0000035859.V332016.R01.S.doc Version 5.2 Page 31 - 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. 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