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Inspection on 31/08/05 for Beulah House

Also see our care home review for Beulah House for more information

This inspection was carried out on 31st August 2005.

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 but made no statutory requirements on the home.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

This home is for adults with severe learning difficulties and the service users are looked after well. The staff were seen to be following the individuals` care plans and working to maintain and improve their current skill levels and take part in a variety of activities that they clearly enjoy. The building itself provides a spacious, pleasant and personalised environment for them to live in.

What has improved since the last inspection?

The home has improved the handling and storage of medication since the last inspection as well as introducing a local policy for the handling of complaints.

What the care home could do better:

All of the standards assessed on this occasion were met other than the one relating to medication training which is booked and the manager hopes will be taking place in the near future.

CARE HOME ADULTS 18-65 Beulah House 5 Cemetery Road Market Drayton Shropshire TF9 3BD Lead Inspector Michael Moloney Unannounced 31 August 2005 07:30 st 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 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 Stationary 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. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beulah House Address 5 Cemetery Road Market Drayton Shropshire TF9 3BD 01630 652451 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) MacIntyre Care Mrs Carol Groome Care Home 5 Category(ies) of 4 Learning Disabilities registration, with number 1 Learning Disabilities - over 65 of places Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2005 Brief Description of the Service: Beulah House is a detached property situated in Market Drayton, Shropshire. The home offers access to local amenities and is in keeping with the local community. The home is part of the MacIntyre Care Services organisation and is registered with the Commission for Social Care Inspection (CSCI) to provide accommodation and person care for a maximum of four people with a learning disability under the age of 65 and one person with a learning disability over the age of 65. Service users are provided with a single room. En-suite facilities are not provided. Shared space includes a lounge/dining room and a new fully fitted kitchen. The garden to the rear of the property provides privacy and security and the service users have access to a large fully furnished heated summer house. The home has it’s own transport and service users regularly access the local community. Ms Carol Groom is the Registered Manager and Head of service. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 7.30 a.m. and lasted for 2.5 hours. The manager started work after the first hour. The inspection was carried out by talking with the service users, observing activity within the home, looking at records and case tracking. The nature of the needs and disabilities of some of the service users concerned made ascertaining their views by direct means difficult. Therefore the views of the staff had to be relied on to a great extent. However, observation confirmed that the service users were calm and relaxed in their company approaching them freely when the need arose. What the service does well: What has improved since the last inspection? What they could do better: All of the standards assessed on this occasion were met other than the one relating to medication training which is booked and the manager hopes will be taking place in the near future. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 6 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. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 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 standard(s) 2 The home has an acceptable admissions policy. EVIDENCE: No new service users have been admitted to this home for some time and therefore it was not possible to assess this standard against how they had managed such an event. However, the appropriate policies and procedures were seen to be in place that, if followed, would ensure that any new resident would be appropriately placed there. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 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 standard(s) 6, 7 and 9 The service user plans are comprehensive and updated at appropriate intervals ensuring that the individuals’ needs are met. Where possible service users are consulted and do make decisions about their lives. EVIDENCE: The care plans and the assessments of activities contained the information to enable staff to work towards the service users’ goals. Given the range of needs and the dependency levels of the service users these had, of necessity, involved very little direct input from some of the individuals concerned. These plans had been reviewed by staff on a regular basis. Elements identified within the Individual Plans had also been risk assessed and it was seen that these documents were regularly reviewed safeguarding the safety of the individual concerned. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 15, 16 and 17 Residents are helped and encouraged to keep in contact with their friends and make good use of the local facilities. The home provides good quality food in appropriate quantities. EVIDENCE: Given the dependency and disability levels of the service users it is not possible for their education and occupation to be considered in other than the broadest sense as it is unlikely that they would be able to access the world of work or any of the mainstream education establishments. However, talking to the staff and the manager and reading the individuals records showed that maintaining the self help and mobility skills of the service users has a high priority. They also showed that the service users are also assisted to access activities that they appear to enjoy such as hydrotherapy. Talking with both the service users and the staff it was clear that they use the local facilities as much as is possible. Service users talked about doing the weekly shopping with the staff and shopping for their own belongings. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 11 Friends outside the home are obviously encouraged. The files showed that each of the residents has access to an advocacy service. The residents had breakfast during the inspection and it was obvious that they were given a choice about what they ate. The records showed that they are also able to have a wide variety of choice for their main meals. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 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 standard(s) 18, 19 and 20 The personal and healthcare needs of the service users are met. EVIDENCE: The records contained instructions about how each individual service user preferred to be approached and helped. Staff seemed to be aware of these likes and dislikes from the way that they were seen to be talking and interacting with them. They were also discreet in the way that they dealt with the personal care of people who needed it with all of the service users looking tidy and well cared for. The records also identified the medical needs of each individual as well as showing how they should be and are met. The home has to manage the medication for the service users. Staff are currently about to undergo further training in this although the system for administration and storage of medication was being followed ensuring that the right people get the correct medication at the right times. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The service users are protected from abuse and the staff enable their views to be taken into account despite the nature of their disabilities. EVIDENCE: The manager reported that they had received no complaints or any allegations of abuse since the last inspection. The home had a copy of the local policies and procedures for the protection of vulnerable adults as well as a copy of their own complaints procedure both being part of the systems that ensures that the service users are listened to and protected from abuse, neglect and self-harm. Although the level of the disabilities of the service users means that they are unlikely to be able to access these formal policies observation of the staff interacting with them and communicating between themselves indicated that they would be aware of any dissatisfaction expressed and it was seen that a whistle blowing policy is available to be used. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 The standard of the environment is good providing service users with an attractive and homely place to live. EVIDENCE: The home is situated in Wem and is an older property that has been converted to its present use in a sensitive and practical manner that is consistent with others in the neighbourhood. The home is in good repair and is both bright and airy providing a homely atmosphere for those living there. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 36 The home ensures that enough staff are available to carry out the service user plans. Those staff receive the necessary supervision. EVIDENCE: Talking to the staff and looking at the staff rota showed that appropriate numbers of staff are on duty at all times. Records were seen that showed that the staff received regular supervision and more regularly than the standards require as the need arose. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 42 The manager is qualified to manage the home and the premises are maintained in a safe manner. EVIDENCE: The manager was pleased to report that she has now obtained both her registered managers award and NVQ4 in care proving her well qualified to manage the home. Accident and fire prevention records were seen to be appropriately maintained and records showed and the manager confirmed that Portable Appliance Testing had taken place ensuring a safe environment for the service users. Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x x 3 x x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Beulah House Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 x x x x 3 x E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 18 yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 20 Regulation 18(1)c Requirement External medication training for all staff must meet Standard 20.10. Timescale for action 31/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection 1st Floor, Chapter House South Abbey Lawn Shrewsbury SY2 5DE National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beulah House E56 E01 S20703 Beulah House UAI V242896 310805 Stage 4.doc Version 1.40 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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