Care Home: Beech Cliffe Grange Residential Home

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What the care home does well The staff were excellent at meeting people`s health and social care needs. Relatives confirmed that staff had a good understanding of younger people with autism. Strategies to manage people`s behaviour were recorded in detail and consistently applied. Appointments with consultants were well managed to ensure information was passed to all appropriate staff. Relatives confirmed information about the care of their relatives was very good, and relatives said they were encouraged to play an active part in decisions made in the person`s best interest. Skills programmes were excellent, with support from a dedicated staff group. There was a consistent approach to enabling people to develop new and existing life skills. Staff were observed supporting people to prepare their own meals, and assisting with daily routines around the home. Staffing was arranged to enable people to be supported on a one to one basis, while additional (new) staff shadow more experienced members of staff as part of their induction. Training opportunities were excellent. Staff attends training to gain competencies in dealing with challenging behaviour and care of adults with autism. There was clear management structures with staff designated with specific roles and responsibilities. They each have a clear vision and strive to provide an excellent stimulating environment for people who use the service. Relatives and staff spoke highly of the managers, and the way they conduct their business. The service has good systems to ensure information was shared, including team and senior meetings. They actively promote methods of seeking feedback from families and health and social care professional. This includes surveys and contact with families following home visits. Relatives confirmed these arrangements, and said it was their opportunity to keep in touch with the home. The service has enhanced the way that risk assessments were managed, to improve health and safety procedures. What has improved since the last inspection? Since the last inspection there have been improvements to the way that the home seeks the views of relatives and other health and social care professionals. There was clear evidence from surveys to confirm that relatives were very happy with the care and support provided at the home. Letters and surveys from social workers and hospital consultants describe the home as excellent. Investment in staff training means that the home meets the required 50% of all staff who have achieved NVQ level 2/3. This percentage fluctuates as staff leave and are replaced by staff who do not have the qualification. What the care home could do better: There were robust recruitment procedures; however two staff was found to be working at the home without waiting for a satisfactory CRB (Criminal Record Bureau) check. There was evidence that the CRB had been applied for, although the guidance insists that staff can only commence employment whilst waiting for the CRB, if a (Protection of Vulnerable Adults) POVA 1st check had been obtained. The manager acted immediately to rectify the problem, by making telephone calls to the umbrella body. The inspector was satisfied that the staff identified was appropriately supervised, to ensure people who use the service were not at risk from harm. Medication procedures were well managed. Staff had the required skills to ensure medication was administered safely. Discussion with the deputy manager confirmed that regular audits take place to ensure records and medication was accurate. The way that one person`s medication was administered needs to be reviewed to ensure agreements are gained with regards to disguising the medication in a chocolate bar. Staff said the arrangement had been in place for a number of years, although there was no evidence to confirm the agreement. CARE HOME ADULTS 18-65 Beech Cliffe Grange Residential Home 51 Munsbrough Lane Greaseborough Rotherham S61 4NS Lead Inspector Valerie Hoyle Key Unannounced Inspection 22nd July 2008 09:30 Beech Cliffe Grange Residential Home DS0000068198.V366361.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 Beech Cliffe Grange Residential Home DS0000068198.V366361.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. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Cliffe Grange Residential Home Address 51 Munsbrough Lane Greaseborough Rotherham S61 4NS 01709 557000 F/P 01709 557000 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) Beech Cliffe Ltd Mrs. Patricia Ann Ratcliffe Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st August 2006 Brief Description of the Service: Beech Cliffe Grange is a specialised residential care service for ten younger adults with learning disabilities and autism. Staffing levels are high, usually one to one, in order to promote positive behaviours and development of independence and skills. Beech Cliffe Grange is a detached dwelling, set in its own extensive grounds and provides accommodation that meets all the spatial environmental requirements. It is located in a residential area of Munsborough, and is close to the local shops of Greasborough. Information gained on the 22nd July 2008 indicates that the current fees are £1762.00. Additional charges include days out, horse riding and personal toiletries. The home provides information to people who use the service and their relatives prior to admission into the home. Service Users Guides are available on request from the manager. The last published inspection report is available on request and a copy is available for visitors to read. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 stars. This means that the people who use this service experience excellent quality outcomes. This unannounced inspection of this service took place over 6 hours starting at 09:30 to 15:30; this included a partial inspection of the home. One person who uses the service, one relative and seven staff were spoken to during the visit; their views were included throughout the report. Occupancy at this home is consistently high. All 10 beds were occupied on the day of this inspection. Two peoples care plans were looked at. Policies relating to medication, complaints, protection of vulnerable adults and handling of people’s monies were looked at. Four staff recruitment and training records were examined to assess how people were protected. Procedures and risk assessments relating to health and safety were looked at and discussed with the deputy manager. An ASR (Annual Service Review) was carried out on the service on 29th January 2008. The outcome of the review confirmed people continue to receive a excellent level of service. The registered providers are Patricia Anne Ratcliffe, and John Henry Ratcliffe. Patricia Anne Ratcliffe is the registered manager and together they have a wealth of knowledge and experience caring for younger adults with a diagnosis of autism. The AQAA was sent to the home in November 2007, this was returned to us after a short extention was granted, which demonstrates responsiveness and cooperation. An annual quality assurance assessment (AQAA) is a self-assessment and a dataset that is filled in once a year by all providers whatever their quality rating. It is one of the main ways that we will get information from providers about how they are meeting outcomes for people using their service. The AQAA also provides us with statistical information about the individual service and trends and patterns in social care. The inspector would like to thank everyone who agreed to being interviewed as part of the inspection process, and the friendliness of staff. What the service does well: The staff were excellent at meeting people’s health and social care needs. Relatives confirmed that staff had a good understanding of younger people Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 6 with autism. Strategies to manage people’s behaviour were recorded in detail and consistently applied. Appointments with consultants were well managed to ensure information was passed to all appropriate staff. Relatives confirmed information about the care of their relatives was very good, and relatives said they were encouraged to play an active part in decisions made in the person’s best interest. Skills programmes were excellent, with support from a dedicated staff group. There was a consistent approach to enabling people to develop new and existing life skills. Staff were observed supporting people to prepare their own meals, and assisting with daily routines around the home. Staffing was arranged to enable people to be supported on a one to one basis, while additional (new) staff shadow more experienced members of staff as part of their induction. Training opportunities were excellent. Staff attends training to gain competencies in dealing with challenging behaviour and care of adults with autism. There was clear management structures with staff designated with specific roles and responsibilities. They each have a clear vision and strive to provide an excellent stimulating environment for people who use the service. Relatives and staff spoke highly of the managers, and the way they conduct their business. The service has good systems to ensure information was shared, including team and senior meetings. They actively promote methods of seeking feedback from families and health and social care professional. This includes surveys and contact with families following home visits. Relatives confirmed these arrangements, and said it was their opportunity to keep in touch with the home. The service has enhanced the way that risk assessments were managed, to improve health and safety procedures. What has improved since the last inspection? What they could do better: Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 7 There were robust recruitment procedures; however two staff was found to be working at the home without waiting for a satisfactory CRB (Criminal Record Bureau) check. There was evidence that the CRB had been applied for, although the guidance insists that staff can only commence employment whilst waiting for the CRB, if a (Protection of Vulnerable Adults) POVA 1st check had been obtained. The manager acted immediately to rectify the problem, by making telephone calls to the umbrella body. The inspector was satisfied that the staff identified was appropriately supervised, to ensure people who use the service were not at risk from harm. Medication procedures were well managed. Staff had the required skills to ensure medication was administered safely. Discussion with the deputy manager confirmed that regular audits take place to ensure records and medication was accurate. The way that one person’s medication was administered needs to be reviewed to ensure agreements are gained with regards to disguising the medication in a chocolate bar. Staff said the arrangement had been in place for a number of years, although there was no evidence to confirm the agreement. 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. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 8 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 Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 9 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 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service receive a full assessment before they are admitted into the home. EVIDENCE: All new people receive a comprehensive needs assessment before admission. The assessments were carried out by the registered provider who has a wealth of knowledge and experience of younger people with autism. The service was highly efficient in obtaining a summary of any assessment undertaken through care management arrangements, and insists on receiving a copy of the care plan before admission. Individuals and their families were supported and encouraged to be involved in the assessment process. Information was gathered from a range of sources including other relevant professionals, and social care professionals. The assessment focuses on achieving positive outcomes for people and these includes ensuring that the facilities, staffing and specialist services provided by the home meet the needs of the individual. A visiting relative was able to confirm the admissions process. He said the home had provided an excellent environment for their relative to develop as an individual including becoming more independent. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 10 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, 9 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home promotes philosophies to enable people to meet their full potential, with clear care plan instructions and comprehensive risk assessments to maximise their safety and protection. EVIDENCE: Two care plans were looked at, they were comprehensively written and reflected the individuals care needs. Information on the actions and responses required by staff to ensure the person’s behaviour was managed was very specific. This means staff was consistent in their approach. Each person had a detailed skills programme, which outlined daily and weekly plans to develop person’s communication, confidence and skills. They included information on many areas, including: road safety, money awareness, shopping skills, eating skills, preparing snacks and meals, transport, and household tasks. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 11 Comprehensive risk assessments were in place. The plans described restrictions on choice and freedom, as agreed by care management arrangements. Care plans also included information relating to health, personal hygiene, activities, relationships, behaviour and communication. The deputy manager said psychiatric appointments were well managed. Keyworker’s, relatives and the deputy manager attends all appointments. This ensures that information can be shared by relevant people involved in the persons care. Documents looked at confirmed the arrangements. The sections on daily routines were very specific and detailed morning, daytime and night time routines, which ensured a consistent approach to social inclusion. The plans were reviewed regularly. Yearly reviews for two people were looked at and confirmed outcomes for each of the objectives within the skills programmes. A visiting relative said that they were fully aware of their sons care plan and felt that they provided a structured routine that is essential for their son. Staff said they enjoyed working on a one to one basis and felt this was essential to the person they were supporting. An interview with a member of staff said that he was fully aware of the needs of the person he supported; he said he found the information was comprehensive and he was able to have regular discussions about the person’s progress. Risk assessments were in place in the two persons looked at. Risk management strategies had been identified and recorded in the individual plan. The plans evidenced that individual activities and choices were respected and supported within a risk management framework. The staff supports people with their personal monies, as they find this aspect of daily life difficult to manage. Clear documentation is used to demonstrate how money is spent and an audit of two persons money was undertaken and was found to be correct. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 12 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, 17 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People were able to make choices about their life style, and supported to develop their life skills. Social, educational, cultural and recreational activities meet people’s expectations. EVIDENCE: Skills programmes were developed for all people and these were looked at and discussed with staff at the home. Staff described in detail the skills that they helped people develop. One person had been shopping for their lunch while others had spent time doing jig saws and using the arts and crafts room. Staff were able to make decisions on activities if the person they were supporting was having a particular difficult day. They undertake risk assessments to ensure it was safe to take people out into the community. People were assisted to maintain regular contact with their family via phone calls and organised visits to parents. The head of care said that staff might go Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 13 with people when they visit parents, to ensure the visit is successful. This was confirmed a by a visiting relative who was taking his son out for the day. He said staff always provides an escort which makes the visit go smoothly. Feedback sheets were sent to relatives after every home visit to assess if the visit had been successful. The form also gives the parent/guardian an opportunity to comment on the care of their relative and raise any concerns. A sample of the feedback forms were looked at. Relatives said they were encouraged to complete quality surveys and be involved in the care of their relative. Holidays away from the home were organised and paid for by the registered providers. Staff provides escorts for the people to ensure they were safe and protected. People were also given opportunity to take holidays with their parents, and the head of care said holidays were currently taking place with two people spending a few days away at the homes caravan. A staff member said he had taken his key resident and it had been a success with the person having a good time especially in the games arcades. Mealtimes were organised around the routines of the people who use the service. The main meal was generally provided at teatime when it was expected that most people would be at home. Packed lunches were provided for those people who were out for the day and some people were encouraged and supported to make their own lunch in one of the training kitchens. Lunch at the home was observed, staff were seen supporting people to eat their meal. Staff prompted people to clear away plates and cutlery, and people were encouraged to lay the tables for the next meal. Beech Cliffe Grange Residential Home DS0000068198.V366361.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, 20 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health and personal care that people receive was based on their individual needs. The principles of respect, dignity and privacy were put into practice. EVIDENCE: The deputy manager takes lead responsibility for the healthcare needs of people who use service. She said people were escorted to medical appointments by staff and comprehensive records were completed ensuring information was shared with those who care for the individual. A visiting relative said staff was very good at keeping them informed if their son/daughter was unwell, they were also encouraged to attend medical appointments and the deputy manager writes to them in advance of the appointment. People have access to consultants who support staff to ensure treatment programmes were followed. Consultants and family members were included in any reviews, to ensure consistency regarding healthcare needs. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 15 There was a good, detailed medicines policy in the home covering all aspects of medicines management and the latest national guidance. This means that staff have information on how to manage medication so that best practice was always followed. The current Medication Administration Record (MAR) charts were looked at. There was a list of staff authorised to administer medicines and examples of their signatures. This means it is possible to identify who was involved in administration if a query or problem occurred. Staff had undertaken training to ensure they understand the procedures for the safe administration of medication. An audit of the medication and records showed them to be accurate and the pharmacist also undertakes medication audits and was always available for advice. Completed pharmacist audits were looked at and they confirm good practice. Discussion with the deputy manager, highlighted that one person received their medication by disguising it in a chocolate bar. Their was however, no up to date agreement with health care professionals, although staff said the agreement had been practice for a number of years. Beech Cliffe Grange Residential Home DS0000068198.V366361.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, 23 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service had access to a robust, effective complaints procedure, and were protected from abuse, and had their rights protected. EVIDENCE: The home had a complaints procedure that was available to people and visitors. The procedure was also referred to in the information given to new people, identifying the stages to follow; this includes the time scales to respond to complaints. The address and telephone number of the Commission for Social Care Inspection was included in the procedure. The AQAA told us that the home had not received any complaints, and this was confirmed by looking at the complaints records. The manager confirmed that complaints received would be actioned within the timescales stated in the procedures. The homes quality assurance surveys confirmed that they were happy with the way concerns were dealt with. The policies and procedures regarding protection of people were of a high quality and were regularly reviewed and updated. However, the home had not obtained a copy of the new adult safeguarding procedures, although the manager said they would obtain a copy immediately. The manager was clear when incidents need external input and who to refer the incident to. Staff receive regular refresher training on the safeguarding adults, and were fully aware of the whistleblowing procedures. Staff spoken to had a good Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 17 understanding of the safeguarding adult’s procedures and the signs which could indicate an abusive situation. Beech Cliffe Grange Residential Home DS0000068198.V366361.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, 30 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home provides a well-maintained safe environment suitable for people. The home provides a clean and hygienic environment to maintain the health and safety of people who use the service. EVIDENCE: A partial tour of the building found it to be clean and fresh. Staff were commended for maintaining good hygiene standards. The home provides a number of training rooms to enable people to pursue life skills, including an art room, training kitchens, and computer and games room. There was also a sensory room for people to spend time in a relaxed environment. The home stands in extensive grounds and has an enclosed area that is lawned and has a cycle track around its perimeter, which is popular with people who use the service. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 19 The registered provider continues to improve the décor and furnishings at the home creating comfortable and safe environments for people. Quality audits and excellent maintenance records were looked at and discussed with the deputy manager, who has lead responsibility for this area. Beech Cliffe Grange Residential Home DS0000068198.V366361.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, 35 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff in the home were trained, skilled and in sufficient numbers to support the people who use the service, in line with their terms and conditions, and to support the smooth running of the service. EVIDENCE: Staffing was arranged on a one to one basis to ensure the complex needs of people can be met. The staff works in two distinct groups working twelve-hour shifts, to ensure consistency for people who use the service. There was a senior structure in place with a deputy manager, head of care, a principal carer and two senior carers on each shift. Care staff makes up the remaining staff. Training continues to be a high priority for staff, which demonstrates a commitment to developing the workforce. A training matrix (training plan) was used to identify gaps in individual’s knowledge, and the head of care has responsibility to nominate staff onto both internal and external courses. Specialist training was also provided and the staff had completed training in dealing with challenging behaviour and breakaway techniques. Comprehensive Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 21 training and supervision records were examined and these meet the requirements of the above standards. There was a comprehensive induction programme and the head of care had responsibility to ensure the ongoing supervision of new staff. One staff interviewed confirmed he could access good training, which ensures he has all the skills required to care for people. Staff had achieved above the required 50 NVQ qualified staff and a number had also achieved NVQ level 3. Seven staff continues to work towards achieving an NVQ award. Four staff recruitment files were looked at to check how people were protected by robust procedures. The files contained applications forms, references and interview records, although two files did not contain a CRB check (Criminal Record Bureau). None of the files examined had a record confirming a POVA (Protection of Vulnerable Adults) check had been received prior to commencement of employment. The manager said that they had a strict policy that staff never work unsupervised with people who use the service, until the CRB was received. Staff rotas and observations during this inspection confirmed the arrangements. The manager acted promptly to check with the umbrella body about the POVA check and arranged for them to be undertaken with immediate effect. The providers were also considering changing the umbrella body so that the required checks would be undertaken in the future. Beech Cliffe Grange Residential Home DS0000068198.V366361.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, 42 People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service were protected by sound management practises, and their views were actively sought to improve the service. Good health and safety procedures ensured they were safe. EVIDENCE: The registered providers/managers have a wealth of knowledge, skills, and competencies in particular they specialise in the care of people of adults with autism. They have appointed deputy managers who have specific responsibilities within Beech Cliffe Grange and the sister home Beech Cliffe. Both deputy managers hold the relevant management qualifications, and the heads of care also hold NVQ level 4 qualifications. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 23 The managers were able to describe a clear vision of the home based on the organisation’s values and priorities. The managers communicates a clear sense of direction, was able to evidence a sound understanding and application of ‘best practice’ operational systems, particularly in relation to continuous improvement, customer satisfaction, and quality assurance. Quality audits were completed in all aspects of the home and feedback from several relatives, social care and health care professionals were looked at. They were very positive about the service provided at the home. One relative confirmed complete satisfaction regarding the care provided to his relative. The manager ensures that staff follows health and safety policies and procedures of the home. Staff have practice handbooks and easy access to training materials and documents. Practice and performance are discussed during supervision, staff training and team meetings. Spot checks and quality monitoring systems provide management evidence that practice reflects the homes and organisation’s policies and procedures. The deputy manager had taken lead responsibility for risk assessing (health and safety) all aspects of the home and has produced excellent tools to ensure people and staff work in a safe environment. There was full and clearly written recording of all safety checks and accidents, including analysis, and there was no evidence of a failure to comply with statutory reporting requirements and other relevant legislation. The home proactively monitors its health and safety performance and consults other experts and specialist agencies about health and safety issues as required. Beech Cliffe Grange Residential Home DS0000068198.V366361.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 4 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 3 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 2 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 4 X 4 X X 3 X Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 25 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 YA34 Regulation 18 Requirement Staff must not work unsupervised until they receive a CRB (Criminal Records Bureau) and POVA 1st checks (Protection of Vulnerable Adults) to ensure people who use the service are safe and protected. Evidence of a POVA 1st check must be sent to CSCI for all staff identified as working without a CRB. Timescale for action 01/09/08 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 YA20 Good Practice Recommendations A new agreement should be developed with regard to the administration of medication covertly, as identified during the inspection. Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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 Beech Cliffe Grange Residential Home DS0000068198.V366361.R01.S.doc Version 5.2 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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