Inspection on 14/02/07 for The Beeches

This inspection was carried out on 14th February 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 no outstanding requirements from the previous inspection report, but made 3 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 07/02/06

The Beeches 13/09/05

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 Bronwynn Bennett Unannounced Inspection 14th February 2007 09:20 The Beeches DS0000026338.V321131.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 The Beeches DS0000026338.V321131.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. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Beeches Address 20b & 20c Parker Lane Mirfield West Yorkshire WF14 9PA 01924 491678 F/P01924491678 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 Mrs Jillian Crowther Care Home 12 Category(ies) of Learning disability (12) registration, with number of places The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 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.V321131.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by one inspector. The visit began at 9.20 am and finished at 3.20 pm. During this visit the inspector spoke to some service users, some of the staff and the home’s manager. The inspector read records of people’s care and staff records, looked at how medicines are given and looked at the accommodation available in the home. There were some service users at the home on the day of this visit. The Beeches is registered for twelve service users. Before this visit, the Commission for Social Care Inspection sent out questionnaires. Twelve questionnaires were sent to service users living at the home and nine were returned. Surveys were sent to twelve service users’ relatives and six responses were received. Other information used as part of this inspection includes notifications from the home about illnesses, accidents and incidents. Before we visited, the manager completed a pre inspection questionnaire. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The Beeches and Briarwood provide the level of care that service users are satisfied with. Service users are supported to develop skills and interests and maintain links with the local community. Service users are supported to take part in activities. People are supported to make their own decisions. Staff offer a good level of support to service users around health care issues. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 6 The staff work hard to ensure service users maintain relationships with family and friends. The home works well to ensure staff receive the training they require to meet the needs of service users. Specialist equipment is provided to help service users reach their full potential. 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 summary of this inspection report can be made available in other formats on request. The Beeches DS0000026338.V321131.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 The Beeches DS0000026338.V321131.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): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs of service users are assessed prior to their admission into the care home. EVIDENCE: The individual needs of service users are assessed prior to admission into the care home. The manager explained that there are two way visits with staff and potential service users, their parents and relatives, to ensure The Beeches is the right place for them. The service users who responded to the survey said they were asked if they wanted to move into the care home. They also said they received enough information about the care home prior to moving in. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ assessed and personal needs and goals are recorded in their plan of care. The support required by service users to make decisions and the risks taken as part of an individual’s lifestyle are appropriately recorded in care records. EVIDENCE: The information received from all the surveys indicates that service users are always treated well by the staff. All the respondents to the relatives’ surveys said they were satisfied with the overall standard of care provided. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 10 The discussions with staff showed they had a good understanding of people’s individual care and support needs. The service users spoken with said the staff were helpful and supportive. The staff were observed interacting well with service users and respecting their right to make decisions. The staff advised the inspector of individuals’ methods of communication. During this visit, service users were observed going about their daily lives. Some individuals had gone out to college, others had chosen to go out for a walk with staff and some people had decided to stay at home. The home is split into two sites. Both areas provide a relaxed and homely atmosphere. The care records for two service users were looked at. The information was person centred with specialist interventions and individual personal care needs recorded. Risk assessments are carried out for any identified risks for each individual. There is a link between care records and some of the risk assessments. This is good practice as it directs staff to the appropriate information. Some risk assessments were in need of updating. The records give clear, easy to follow information that outlines the level of risk and the measures in place to minimise the risk and any associated hazards. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 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. 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 this service. Service users are supported to be part of the local community and take part in appropriate activities. Individuals are supported to maintain relationships with family and friends. The service users’ rights and responsibilities are respected. Service users are offered a choice of food that meets dietary, cultural and religious needs. EVIDENCE: Service users are supported to take part in educational activity and some individuals attend a local college. A gardening project that will be accessible to all individuals is currently being developed at the main Hollybank site. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 12 During this visit, service users were seen being supported by the staff to go out and take part in their chosen activity. The service users spoken with said they enjoyed taking part in the activities available to them. Service users are supported to be part of the local community. During this visit, some individuals had gone out to college, others had chosen to go out for a walk with staff. Some people were being supported to go to the hydrotherapy pool and rebound centre. Dicussions with some individuals showed that there are preparations underway for holidays. One service user was very excited about their planned trip abroad. In addition to holidays, service users have planned weekends away and go out to other events. It was noted that there were sufficient staff on duty to support the service users to take part in their chosen activity. The staff work well to ensure service users have access to a variety of activities. Information received by the CSCI indicates that service users are supported to make decisions about what they do each day. During this visit, individuals were seen being supported to make their own decisions. The staff work well in addressing the cultural needs of service users. Individual relationships with family and friends are supported and the people who are important to the individual were seen recorded in their records. A service user said that they have regular contact with their family. The information from all the relative questionaires states that the staff welcome them in the home and they are able to see their relative in private. The staff were seen to be kind and caring towards the service users. There was good interaction and relationships noted between individuals and the staff. Staff were observed treating individuals in a respectful and dignified manner during this visit. Where individuals are supported to carry out domestic tasks, this is recorded in the records kept. Meals served at the home are flexible and service users assist in the planning of meals. During this visit, meal times were relaxed and staff were giving people the right sort of help to eat their meals. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 13 The preparation and serving of food respects individual dietary, cultural and religious needs. The Beeches DS0000026338.V321131.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 good. This judgement has been made using available evidence including a visit to this service. The service users receive personal support in their preferred way with their individual health care needs being met. Greater care is required to ensure the home’s medication policy and procedure protects the service users. EVIDENCE: The service users’ preferred times for bathing, meals and choice of clothing were seen recorded in the individual records kept. Service users have some choice of staff who work with them. Their cultural and religious needs are respected. The information seen in the care records was good and shows the staff exactly how the person wishes to receive their care. Information of the movement and support the person requires is recorded. During this visit, service users were observed receiving their care and support in a caring and respectful way from the staff. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 15 A relative commented that the staff had been very good in managing with their relative’s health condition. Individuals are supported to access NHS healthcare facilities and access visits to their GP. Service users have the equipment they need in order to maximise their independence. During this visit, a service user said they were receiving a visit that day regarding a sleep system. Another service user was visited and received additional equipment for use of their wheelchair. The medication was looked at for two service users and one of the records was correct. One medication had not been carried forward from the previous month on to the current MAR sheet (Medication Administration Record). This was discussed with the manager who agreed to take action to rectify the matter. The Beeches DS0000026338.V321131.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 good. This judgement has been made using available evidence including a visit to this service. Generally, service users feel that their views are listened to and acted upon, and they are protected from abuse. Greater care is required with the home’s policy and procedure relating to service users’ money. EVIDENCE: The home has a complaints policy and procedure displayed that is available in suitable formats for service users. Service users that responded to the survey said they knew who to speak to if they were not happy and three said they knew how to make a complaint. Four relatives said they were aware of the home’s complaints procedure. A service user spoken to during this visit said they would speak to a member of the care staff if they were unhappy or if they had a concern. The home has received two complaints since the last visit by the CSCI that have been dealt with through the home’s complaints policy and procedure. All staff have completed adult protection training. The staff spoken to had a good understanding of vulnerable adults policy and procedure, and the The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 17 necessary actions that must be taken should there be any alleagations of abuse. The personal money for two service users was checked and one record was correct. However, there was a minor discrepancy in one service user’s money. This was discussed with the manager and staff who believed this could be accounted for, but not properly recorded by the staff responsible. The manager said she would to take action to rectify the matter. The Beeches DS0000026338.V321131.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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users live in an environment that is generally comfortable, safe, clean and hygienic. EVIDENCE: A tour of the premises was carried out and the home was noted to be generally clean and odour free. Both Briarwood and The Beeches site require some maintenance works such as redecoration and replacement carpets and furniture. The manager said that the required works and replacement items would be adressed shortly. There was some flood damage seen in a bathroom during this visit which was in need of some replastering work and wall tiles replacing. During this visit, the manager contacted the maintenance department to arrange the required The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 19 repairs. In addition, this area was noted to have stored items such as incontinence pads and laundry items. The importance of service users being able to access personal care in a homely environment was discussed with a senior member of staff and the manager. Eight surveys received by the CSCI commented that the home is always fresh and clean. One respondent said there are sometimes odours in the home. The bedrooms seen during this visit had been decorated and personalised through choices made by the service users. One person showed the inspector their room and explained how they had chosen to personalise it. Service users have access to the equipment they require to maximise their independence. For example, there is appropriate sleeping, seating and bathing equipment to ensure individual care needs can be met. A service user advised that they had made arrangements for a sleep system to be fitted. The laundry areas were seen to be generally clean and well organised, however the laundry area was not fitted with a sink and equipment required for handwashing. This must be addressed in order to promote good hygiene and infection control practices. The Beeches DS0000026338.V321131.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, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff work hard to support the service users. Appropriately trained staff meet the needs of service users. The home’s recruitment policy and procedure is sufficiently robust to protect the service users. EVIDENCE: Some service users require support in order to communicate. The staff were noted to understand individuals’ communication needs. The inspector was also advised of the communication methods required by an individual in order to discuss some of their experience of living at the home. There was some good interaction observed between individuals and staff. The service users spoken with said they felt well supported by the staff team. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 21 Eight service user surveys said the staff always treat them well and the care staff always listen and act on what they say. The staff have received induction training and the required mandatory training. Staff also received training specific to the health and care needs of the service users living at the home. Twenty five per cent of staff have achieved NVQ level 2 training and this training is continuing for all staff. The records for three staff working in the organisation were audited and held the required information. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 22 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): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current management arrangements ensure service users benefit from a well run home. Generally, the home is run in the best interests of the service users. The health, safety and welfare of the service users and staff is generally promoted and protected. EVIDENCE: The manager of the home is Mrs Jillian Crowther. She has good experience of caring for the service user group and has worked for the organisation for five years. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 23 There were some positive comments made about the manager during this visit. Some quality monitoring is carried out within the home. Monthly visits are carried out by a representative of the organisation and there is regular supervision of staff. There are plans to develop the use of service user and relative satisfaction questionnaires. In addition, there are regular service user and staff meetings. The fire records were checked. There were gaps in the records for both The Beechwood and Briarwood site. This is not acceptable. Fire testing must be carried out on a weekly basis and this must include the testing of emergency lighting. The appropriate records, completed in ink, must be kept. This was discussed with the manager who took action during this visit to rectify the matter. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 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 X 3 X X 2 X The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13.2 Timescale for action The registered person shall make 14/02/07 arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The medication records must be kept up to date. All medication carried forward from the previous month must be transferred onto the current MAR sheet. The registered person shall make 14/04/07 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Facilities for hand washing must be sited in the laundry room. The registered person shall take 14/02/07 adequate precautions against the risk of fire. Testing of the home’s fire alarm system, including emergency lighting, must be carried out weekly with the appropriate records kept. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 26 Requirement 2. YA30 13.3 3. YA42 23.4 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. 4. Refer to Standard YA9 YA23 YA24 YA32 Good Practice Recommendations Risk assessments should be reviewed and kept up to date. Service users’ financial records should be accurate and up to date. The maintenance and refurbishment of the home should be carried out in a timely way to ensure the overall environment is appropriate for the needs of service users. Staff should continue working towards completing NVQ level 2 award. The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 The Beeches DS0000026338.V321131.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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