Inspection on 02/11/05 for Bethia Cottage

This inspection was carried out on 2nd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Bethia Cottage 30/07/07

Bethia Cottage 01/08/06

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Bethia Cottage Lelley Road Preston Hull East Yorkshire HU12 8TX Lead Inspector Brian Hallgate Unannounced Inspection 2nd November 2005 09:30 Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bethia Cottage Address Lelley Road Preston Hull East Yorkshire HU12 8TX 01709 375333 01709 721727 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) Milbury Care Services Limited *** Post Vacant *** Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Registered for 5 service users in category LD, some or all of whom may have a physical disability FIRST INSPECTION OF THIS SERVICE Date of last inspection Brief Description of the Service: The home is a detached bungalow built behind an existing respite care unit in an isolated position approximately 2 miles from the village of Preston. There is no access by public transport and service users have to rely on the minibus belonging to the home for transport to the shops and leisure facilities. There are five single bedrooms, one on which is en-suite. The other bedrooms have a toilet, bathroom and washbasin between two bedrooms. There is a lounge, dining room/kitchen, shower room and an assisted toilet. There is garden furniture to the front and side of the home. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 4 hours, including preparation time, and was an unannounced inspection that commenced at 9.30am. This was the first inspection of the service since it was registered. A tour of the home was made with the senior support worker on duty and a number of records were inspected. Three service users and three members of staff were spoken to. The service users have limited verbal communication and staff communicate with them by gestures and signs. The staff were observed interacting with the service users. 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 contacting your local CSCI office. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 6 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 Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 7 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): 2 and 5 The admission procedure is not adequate to ensure that there is a proper written assessment prior to admission and there are no copies of individual written contracts. EVIDENCE: There was no evidence available in the home to show that a care management written assessment had been carried out before the three service users had been admitted to the home. Staff on duty could not produce written contracts or statements of terms and conditions for service users. The manager must ensure that the appropriate documents are obtained before service users and admitted. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 8 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): 6, 7 and 9 There is a planning system in place to provide staff with information about the needs of service users, but no easy way to read about the daily life of service users. EVIDENCE: Although there are comprehensive details of the care each service user needs it would be helpful for newly appointed staff and any relief staff if a daily plan of care was readily available. Although the staff spoken to had a good knowledge of what happens throughout each day and what the needs of the three service users were, this information was not written down in an accessible way. Service users are given a choice of what activities they wish to participate in, what food they wished to eat and what clothes they wished to wear. Although the service users had very limited or no verbal communication skills the staff could demonstrate how they gave them choice. Staff were aware of the non-verbal communication each service user would use if they did not wish to undertake any activity. Risk assessments have been completed on all service users for activities within and outside the home. The completed risk assessments were seen. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 9 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 and 17 Social activities are well organised and provide stimulation and interest for people living in the home. Meals are balanced and offer healthy and varied meals for the service users EVIDENCE: Service users are involved in many social activities, including horse riding, holidays, swimming, bowling, visiting cafes, restaurants and public houses, visiting the local village and shops. The home is isolated and not part of any community. Staff take service users into the village of Hedon, approximately two miles away for shopping and visiting the public house. All the service users are in regular contact with their families. All go home on regular visits for tea. Staff were observed to respect service users rights. Staff stated that if a service user did not wish to undertake a specific activity they were able to take part in an alternative. There is a planned menu. Service users who do not wish to eat the planned meal are offered an alternative. Staff demonstrated the non verbal means of communication that service users used if they did not wish to take part in an activity or eat the meal on the menu. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The health needs of service users are met with good access available to specialist services when required. EVIDENCE: All service users are registered with a GP. Access to specialised medical services are obtained through the GP. Appointments have also been made for service users to see dentists and opticians. From the records and the observations made it appears that the physical and emotional health needs of the service users are being met. All three service users take prescribed medication. No service user is able to self-medicate. All staff had undertaken a medication course during their induction training. The medication and the medication records checked were in order and up to date. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 11 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): 22 and 23 There are satisfactory complaints and abuse policies. EVIDENCE: There is a complaints policy. A complaints book is available in the office. No complaints have been recorded since the home opened. There is an abuse policy and procedure and a copy of the local authority vulnerable adults policy and procedures. Staff were aware of what action to take if a complaint or a suspected abuse situation occurred. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 12 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): 24 and 30 The standard of the environment is very good, providing service users with an attractive and homely place in which to live. EVIDENCE: This is a new purpose build home, opened in August this year. It is well decorated and furnished throughout and gives plenty of space for the service users. There is garden furniture to the front and side of the home and plenty of grassed areas for the use of the service users. The home is very clean, well kept and is hygienic. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 13 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 and 35 The procedures for the recruitment of staff are not robust and do not offer protection to the people living in the home. EVIDENCE: The staff records inspected showed that the appropriate information regarding CRB disclosures and written references were not available. Both files inspected had no satisfactory records that showed the members of staff had received a satisfactory CRB disclosure. One of the files examined only had one written reference. A telephone enquiry was made to the Human Resource Department of the organisation. Dates of the CRB disclosures were obtained but they had no record of a second written reference for the member of staff. One date of the CRB clearance clearly showed that this member of staff had been working with vulnerable adults before the CRB disclosure was received by the organisation. Members of staff must not work with vulnerable adults until the necessary CRB clearance and references have been obtained. Staff had undertaken a comprehensive induction programme before the home opened. The training included first aid, medication, introduction to learning disabilities, food hygiene, risk assessments, pressure care, supervision skills, fire prevention, report writing, autistic syndrome, vulnerable adults, epilepsy and challenging behaviour. Some staff have qualifications in NVQs at Level 2, 3 and 4. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 14 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 and 42 The home is managed in an open and inclusive manner by the manager who enjoys the support of the staff. EVIDENCE: At the present time there is no registered manager of this home. The manager has applied to become the registered manager and the application is at present pending. All staff spoken to stated that the home was well managed. Positive feedback had been received from the relatives of the service users. As this is a new service the quality of the care provided had only been obtained on an informal basis. There are plans to conduct a quality monitoring exercise at a later date. All aspects of the health and safety records checked were up to date and in order. Bethia Cottage DS0000062728.V262915.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 1 x x 1 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 3 x 1 3 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bethia Cottage Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 x DS0000062728.V262915.R01.S.doc Version 5.0 Page 16 N/A 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 2 Regulation 14 Requirement Assessments must be completed before service users are considered for admission to the home. Service users must have a written contract of their terms and conditions of their placement. All staff must have a CRB disclosure and two written references before working with vulnerable people. Timescale for action 15/11/05 2 5 15 15/11/05 3 34 19 15/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 6 Good Practice Recommendations Service users should have a written daily plan of care. 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