Inspection on 07/02/06 for The Beeches

This inspection was carried out on 7th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 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 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 Cathy Howarth Unannounced Inspection 7th February 2006 10:00 The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 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.V263374.R01.S.doc Version 5.1 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.V263374.R01.S.doc Version 5.1 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.V263374.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 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.V263374.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over a four and a half hour period. The inspector visited both properties forming the service, met with service users and staff, and examined relevant records relating to the standards assessed. On the whole, the inspector found that the people living there view the service positively. Service users have good opportunities for choosing their own lifestyle and have good levels of staff support to facilitate this. The inspector would like to thank service users and staff for their welcome and co-operation during this visit. What the service does well: What has improved since the last inspection? More staff have completed the basic training courses and are registered for NVQ training. Some improvements have been made in the environment to make the home safer and to improve the state of some rooms. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 Page 6 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.V263374.R01.S.doc Version 5.1 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.V263374.R01.S.doc Version 5.1 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 The service user guide needs to be available for all. EVIDENCE: At the last inspection it was identified that the service user guide was not available. Work has progressed on this and a draft has been produced, although the timescale given has not been met. However, the document is still not available for prospective service users nor for those people currently using the service. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 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 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. EVIDENCE: Care plans for service users showed that individual support plans are in place for each service user. These detail issues of importance around personal care, leisure, family contacts and any other issues of importance to service users. There were some details on some files that need to be completed, for example around financial arrangements for service users. The home has started using Person Centred Planning within its care planning systems. This is basic but gives a good outline of how service users receive support and what is important to them. One care plan examined had a good indication of the person’s method of communication using photos of the individual and an explanation of the meaning of each expression or gesture. This is a very simple but effective way of ensuring that staff know how to communicate with individuals. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 Page 10 Risk assessments were in place for each service user and were found to be appropriate and up to date. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 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): 14 Service users at The Beeches have good leisure opportunities. EVIDENCE: At the time of this visit many of the service users were out of the home, engaged in activities within the local community. As the usual college activities were closed for a two-week period, a plan for activities was in place to ensure that individuals had plenty of opportunities for other stimulating activities. These included trips to local sites of interest, shopping trips and trips further afield such as to the seaside. The home has access to plenty of vehicles which makes it easy for people to get out and about and to follow their individual interests. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 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 the following standard(s): Improvements are needed in the management of medication within the home. EVIDENCE: No service users managed their own medicine at the time of this inspection. The procedures followed by staff are largely well controlled and ensure safe handling. However, the inspector found a ‘dump pot’ in use in each house, into which unused tablets were being put and kept, rather than being returned to the pharmacist. Such a use is not safe and the practice should cease. Unused medicines in blister packs need to be returned to the pharmacist at the end of each month or, if there is a change of medicine then the pharmacist should be contacted to correct the packs. The other problem identified was the practice of keeping medicines that are no longer in use rather than returning them. The cupboard should be checked routinely every month and any out of date or unused medicines should be returned for disposal. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 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 the following standard(s): 23 The systems and procedures followed by the staff team make sure that people are protected against abuse and self-harm. EVIDENCE: All staff receive basic training in issues relating to the protection of vulnerable adults. Some staff, mainly senior staff, have also received further training in this area. Staff on duty at the time of this inspection were able to give a good account of the procedures they would follow should they have any suspicions of mistreatment or if a complaint was made to them. Given the nature of this client group, it is vital that staff are vigilant for any signs of abuse. Staff on duty demonstrated an awareness of possible signs. The Hollybank Trust has robust systems and procedures to deal with these kinds of issues, including a whistle-blowing policy and policies and training around intimate care for service users. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 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 the following standard(s): 25, 26 Bedrooms generally suit individuals’ lifestyles and promote their independence. EVIDENCE: The bedrooms at The Beeches are spacious with ensuite facilities for one service user. In Briarwood, the bedrooms do not have ensuite facilities. The Hollybank Trust is in the process of planning developments in relation to improving the facilities at Briarwood. This is a positive step and will be of benefit to those service users affected. Bedrooms are individually decorated and reflect the occupants’ personal tastes. They are also equipped to meet individual needs with appropriate sleep systems or bathing equipment. At the last inspection visit, a number of issues relating to the environment were identified as needing improvement. These have largely been addressed. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 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 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): 35 Service users benefit from a well-trained workforce. EVIDENCE: Staff at The Beeches receive basic training as part of their induction which covers a range of basics that they will need to be able to meet the needs of service users, such as moving and handling, basic food hygiene and infection control. In addition the Hollybank Trust has an extensive range of courses on offer for all levels of workers within the workforce. Staff have attended such courses as optical awareness, epilepsy and disability awareness provided by the Trust. Since the last inspection more staff have been registered for NVQ2 training. Progress is being made but the home has not yet reached the target of 50 qualified staff. Observations of staff with service users showed that, on the whole, staff demonstrate a high level of skill in approaching service users with tact and discretion in meeting personal care needs. The inspector did observe one or two social situations where there seemed to be a lack of inclusion of service users in conversations. This was cause for some concern but was not typical of the interactions observed within the home. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 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 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 and 39 The home is well run by the current manager. Quality Assurance systems seek continuous improvement within the service. EVIDENCE: The current manager of The Beeches is in the process of registration by the Commission for Social Care Inspection. The evidence from this inspection is that the manager is making steps in improving the service and has a development plan for the service which should benefit all service users in time. In terms of Quality Assurance, the Trust has systems in place to audit the service for quality at various times. In January, the Head of Residential Services sent questionnaires to all workers to elicit their views. At other times service users and their relatives have been surveyed for their views. There are regular service user meetings which seek to gain the views of those people receiving a service. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 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 Standard No Score 1 1 2 X 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 X 23 3 ENVIRONMENT Standard No Score 24 X 25 3 26 3 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 1 X 3 X 3 X X X X The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? YES 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 medicines in the home must be properly stock controlled and unused medicines should be disposed of appropriately Timescale for action 31/10/05 2. YA20 13(2) 28/02/06 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 YA32 Good Practice Recommendations A minimum of 50 of staff should have NVQ2 qualification by the end of 2005. The Beeches DS0000026338.V263374.R01.S.doc Version 5.1 Page 19 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.V263374.R01.S.doc Version 5.1 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. 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!