Inspection on 13/09/05 for The Beeches

This inspection was carried out on 13th September 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Beeches 09/03/09

The Beeches 14/02/07

The Beeches 07/02/06

The Beeches 15/02/05

The Beeches 06/04/04

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 09/07/2008.

CARE HOME ADULTS 18-65 The Beeches 20b & 20c Parker Lane Mirfield West Yorkshire WF14 9PA Lead Inspector Cathy Howarth Announced Inspection 13th September 2005 09:00 The Beeches DS0000026338.V251849.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 The Beeches DS0000026338.V251849.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. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Beeches Address 20b & 20c Parker Lane Mirfield West Yorkshire WF14 9PA 01924 491678 01924 491678 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) Holly Bank Trust Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th February 2005 Brief Description of the Service: The Beeches is a care home providing personal care and accommodation for twelve younger adults with moderate to profound learning disabilities and associated physical disabilities. The care home is managed by the Hollybank Trust, a voluntary organisation that specialises in the area of learning disability and operates several facilities for this user group. The accommodation consists of an adapted house and a bungalow on the same site, each providing accommodation for six people. The accommodation is sited in a residential area of Mirfield, a small town midway between Dewsbury and Huddersfield. The bulk of the accommodation is on the ground floor. All service users have single rooms. The accommodation has large multi-level gardens. The central area between the two houses is used for parking. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced and was conducted over an 8 hour period. The inspector looked at all areas of the two buildings that make up the home, met with service users and staff and observed a meal with service users. The inspector also looked at records within the home. Questionnaires were sent to service users and relatives before this inspection, six service users and twelve relatives responded. These responses were overwhelmingly positive about the service. What the service does well: The service is good at ensuring service users have a good introduction to the home. The service is good at identifying and meeting needs of service users in a way that reflects their preferences and maintains their independence as far as possible. Service users have good opportunities for self-development and to adopt a lifestyle that suits them. Individual choices and rights are respected. Meals are healthy and nutritious. Personal preferences of service users are respected. Health issues are addressed adequately. The home is clean and tidy and well maintained and offers a comfortable environment for service users. There are sufficient staff on duty to meet the needs of service users. Health and safety issues are treated seriously within the home. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 6 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. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 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 The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 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): 1,2, The processes for giving information to prospective service users and enabling them to make informed decisions about admission to the home are good but the service user guide needs to be developed. EVIDENCE: The inspector spoke at length with one service user who has recently been admitted to the home. This person explained the process through which they had visited and made the decision to live there. This involved them having opportunities to visit the home and find out what was on offer. Information was given by their social worker but no service user guide was offered as this is still being developed. Part of the process also involved exploring what the service user hoped to gain from living at the home. At the time of the visit their trial period was ending and they were about to have a review and make a decision about staying at the home. The process had gone smoothly from the service user’s point of view and they reported that they were happy with the service and intend to stay. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 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): 6,8,9 The service is good at identifying and meeting needs of service users in a way that reflects their preferences and maintains their independence as far as possible. Some minor improvements are needed however to ensure staff can evaluate their success better. EVIDENCE: The service has good systems for assessing needs of service users. Individual support plans give staff a good guide for the strengths and needs of service users and how they require and prefer support to be offered. In some plans these are linked directly to risk assessments that have been carried out for each service user. This makes it easy for staff to know how to offer support and whether there are any specific risks involved with that particular activity. One omission on the support plans for service users was in the area of communication. Service user preferences and ways of communicating are vital to help staff ensure they are consulting service users properly. Another area for improvement is in the monitoring of goals and plans. For example one service user had a goal which identified that she should cook a particular type of meal once a week. The only means currently of recording this is in the daily notes. This makes it harder to track and, after looking The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 10 through these notes, the inspector found that this goal was not being achieved. A specific means of recording achievement of goals could help to highlight whether or not these are being achieved and allow key workers to act promptly to address such issues in a timely way without waiting for a formal review to take place. Behaviour Management Plans are being introduced to the home where these are necessary. None were seen on the files examined in the course of this inspection. House meetings are held where service users can have input into planning within the home. Service users are routinely involved in decisions about decorating their rooms, decoration of the communal areas of the home and activities to be planned. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 11 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): 12,13,14,15,16,17, Service users have good opportunities for self-development and to adopt a lifestyle that suits them. Individual choices and rights are respected. Meals are healthy and nutritious. EVIDENCE: Service users have good access to a wide range of leisure and educational activities. Local facilities are used as far as possible such as local colleges, cinemas and attractions. Wherever possible, service users are supported and encouraged to maintain relationships with families and friends. Staff support to do this as and when needed. Transport at the home is good with service users using unmarked vehicles to access facilities. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 12 Within the home, service users’ rights and privacy are respected and are encouraged to be independent as far as possible. One service user did identify some area where some extra facilities would help to increase independence, such as an ironing board that could be used easily by wheelchair users. The inspector did observe some service users taking part in daily chores supported by staff and with appropriate aids to make this possible. The inspector observed a meal at the Beeches. This was a well-ordered affair and was a healthy meal with fresh vegetables served. Service users were offered appropriate choices. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 13 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 Personal preferences of service users are respected. Health issues are addressed adequately. EVIDENCE: Service users’ preferences regarding personal support is indicated in the individual support plans and service users gave examples of instances where they have influenced support, such as one service user who has asked for intimate care only to be provided by female staff. Appropriate equipment is provided for individuals as required. The home has support from local health services and also from speech and language therapists and physiotherapists employed by the Hollybank Trust to offer support. Healthcare issues are given a priority and all appointments are recorded on individual files. Staff support service users to attend appointments. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 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): 22 Complaints are managed satisfactorily within the service. EVIDENCE: The home has a complaints procedure which is available in pictorial format as well as written. Service users indicated that they were aware of how to raise issues of concern but were less sure about the formal procedure. Complaints are taken seriously and are recorded in a log. Recent records were examined and found to be adequately addressed by the service. There are no advocates permanently allocated to service users at present. However the service has used the Cloverleaf advocacy service in the past and would use them again should the need arise. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 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): 24,29, 30 The home is clean and tidy and well maintained. Some areas need improvement. EVIDENCE: As part of this inspection all areas of the service were seen. Generally the home was found to be homely, comfortable and in a good state of repair. However some areas are in need of attention: In the Beeches: • Restrictors need putting on windows of the first floor bedroom • Kitchen needs upgrading • One service user needs a repair to walking frame • Bathroom toilet seat needs to be replaced In Briarwood: • The plasterwork in the bathroom needs renovation • Quiet room needs to be cleared of clutter so that it can be used easily. • The gardens also need some clearing and ongoing maintenance to ensure they can be used by all service users. Service users were seen to have appropriate equipment to support them in the home, such as appropriate wheelchairs, seating and bathing aids. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 16 The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 17 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, 33, Staff training is being prioritised more now in the home and progress is being made to ensure staff have the basic skills they need for their job. There are sufficient staff on duty to meet the needs of service users. EVIDENCE: Staff at The Beeches have access to a range of courses to equip them to meet the needs of service users living at the home. The Hollybank Trust provides a wide range of training on a rolling programme. Historically staff at The Beeches have not always attended courses but this has improved more recently. There is a backlog of staff that need training in some basic courses such as Food Hygiene and First Aid. However, there is a plan in place to meet this need and all staff should have attended these basic courses over the next few months. Similarly, staff are now making progress with NVQ2 qualifications. The home does not yet meet the 50 standard but is making progress towards this. Staffing levels at The Beeches are adequate, providing sufficient support within the houses for service users. The inspector did have some question about whether there would be sufficient staff to allow people to do the activities they wish to. However service users and staff explained that this is rarely a problem and staff can be flexible with rotas to ensure there is support available for any specific activities required. Relatives who responded to the questionnaire also indicated that they felt there were sufficient staff on duty. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 18 The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 19 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): 42 Health and safety issues are treated seriously within the home. EVIDENCE: Health and safety records for the home showed that there are adequate systems to monitor this and make sure the home is kept safe. There are regular fire tests and drills. Water temperatures are tested and the system is disinfected regularly. Hazards are identified and risk assessments completed for the home. Gas certificates were found for the houses but no electrical installation certificate was available. The manager agreed to forward this once it is located at the Trust’s head office. Staff routinely receive training in health and safety issues as part of their induction and ongoing training. The inspector observed staff on duty observing hazards and taking appropriate action to prevent accidents during this visit. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 3 x x x x Standard No 22 23 Score 3 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 x 3 3 x x Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x 1 2 x x x CONDUCT AND MANAGEMENT OF THE HOME 3 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 The Beeches Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x DS0000026338.V251849.R01.S.doc Version 5.0 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. 1 Standard YA1 Regulation 5 Requirement The service must produce a service user guide, which is available to all prospective service users and meets the requirements of the regulations. All staff must have completed basic training courses as detailed in this report. Timescale for action 31/10/05 2 YA32 18 31/12/05 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 2 3 Refer to Standard YA6 YA24 YA32 Good Practice Recommendations Individual support plans should include information about how service users communicate. Monitoring of goals should be clearer. The improvements identified in the Environment section of this report need to be made. A minimum of 50 of staff should have NVQ2 qualification by the end of 2005. The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 The Beeches DS0000026338.V251849.R01.S.doc Version 5.0 Page 23 - 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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