Care Home: Beech Trees

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What the care home does well People who use the service are provided with written information they need to enable them to make a choice about living at the home. Assessment documentation is in place to ensure the individual needs of residents can be met. Care plans and risk assessments are in place that ensures residents` needs are met. Residents are supported by staff to lead active and fulfilling lives, and are encouraged to participate in a range of activities both within the home and the local community. A balanced diet is provided for residents. Physical and health care is offered in such a way as to ensure residents` personal, physical and health care needs are met. Residents are provided with a copy of the complaints procedure that has been produced using widget symbols and key words. People using the service are provided with satisfactory communal and individual living space making it a safe and comfortable place to live. The arrangements for staffing are satisfactory, ensuring staff have the training to meet the needs of the residents. The arrangements for management and administration ensure the home is run in the best interests of residents, and their safety is promoted and safeguarded. What has improved since the last inspection? The home had a planned and documented maintenance and renewal programme for the decoration of the home. The sealant around the baths and showers had been replaced as required. The home has a portable wheelchair ramp that can be used to enable wheel chair users to access the garden. The home`s complaint procedure has been updated and includes the current management arrangements. Prescription creams are stored appropriately in locked cabinets in resident`s bedrooms. All staff employed at the home have had the relevant checks undertaken. The kitchen flooring has been replaced. What the care home could do better: Running totals of medication should be maintained on the Medical Administration Record sheets to enable an audit trail to be followed. CARE HOME ADULTS 18-65 Beech Trees 1A Kirby Road Horsell Village Woking Surrey GU21 4RJ Lead Inspector Joseph Croft Key Unannounced Inspection 23rd January 2008 9:55 Beech Trees DS0000055261.V356051.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 Trees DS0000055261.V356051.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 Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Trees Address 1A Kirby Road Horsell Village Woking Surrey GU21 4RJ 01483 276195 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) scilla.roe@brookhurstcare.co.uk Brookhurst Care Limited Pamela Anne Callanan Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Of the adults accommodated, one (1) may also fall within the category PD (physical disability). 10th April 2006 Date of last inspection Brief Description of the Service: Beech Trees is situated in a quiet residential area of Horsell Village, a short distance by car from Woking town centre. Beech Trees is a tastefully converted modern style property, which is a home for young adults with a learning disability. The home is also registered for one young adult with an associated physical disability. The accommodation consists of six individual en suite bedrooms, four of these being on the first floor and two on the ground floor. There is no lift access to the first floor. Communal areas consist of a dining room, sitting room and easily accessible kitchen and laundry room. Both the dining room and sitting room have French doors leading to a medium sized secure back garden. The home has a small area for parking at the front, but parking is available on the road outside. The weekly fees range from £1350 to £1800. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection (CSCI) undertook an unannounced site visit on the 23rd January 2008, using the ‘Inspecting for Better Lives’ (IBL) process. This visit was undertaken by Regulation Inspector Mr Joe Croft and took seven hours, commencing at 9:55 and concluding at 16:55. The registered manager assisted the Inspector throughout the site visit. The Inspector was informed that people using the service prefer to be known as residents, therefore this reference is used throughout this report. The inspection process included a tour of the premises and sampling of residents’ care plans and risk assessments. Other documents sampled included the menu, policies and procedures, records of medication, training records, staff recruitment files and health and safety records. The Inspector had discussions with the manager, three members of staff and one parent who was present at the time of this site visit. Residents were observed to be appropriately cared for, and staff were attending to and supporting individuals as and when required. On the day of the site visit, due to their communication difficulties, discussions took pace with only one resident living at the home. This resident was able to inform the Inspector that they were happy living at the home, “do lots of activities,” and attends a college. The Annual Quality Assurance Assessment (AQAA) completed by the home, and returned to the Commission For Social Care Inspection, has been used as a source of evidence in this report. The Inspector did not receive completed surveys at the time of writing this report. The quality rating for this service is 2 Star. This means the people who use this service experience good quality outcomes. Feedback was provided to the Proprietor and Manager before the end of this site visit. The inspector would like to thank the manager, staff and residents for their cooperation during the inspection. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 7 Running totals of medication should be maintained on the Medical Administration Record sheets to enable an audit trail to be followed. 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 Trees DS0000055261.V356051.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 Trees DS0000055261.V356051.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): Standards 1 and 2 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are provided with written information they need to enable them to make a choice about living at the home. Assessment documentation is in place to ensure the individual needs of residents can be met. EVIDENCE: The home has a Statement of Purpose that had been reviewed in January 2008. This includes information in regard to the aims and objectives, accommodation, philosophy of care and the staffing at the home. The Proprietor, who visited the home for a short time during this site visit, informed the Inspector that the Service Users Guide is currently being updated and will include the use of picture symbols and key words. The Inspector viewed a sample of this document. There are currently five residents living at the home. The Inspector viewed the pre-admission assessment for the most recently admitted resident to the home that was undertaken by the manager. This included information in regard to the personal, physical and health care needs of the resident, and was signed and dated. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 10 The home follows the organisation’s Admissions Policies and Procedures that was last reviewed in March 2007. This provides the procedures to be followed when admitting a new resident to the home, which includes requesting an assessment of need from the placing authority. Prospective residents are encouraged to visit the home, including when possible an overnight stay. This will provide prospective residents with the opportunity to meet other residents and staff at the home. One parent, who was present during the site visit, informed the Inspector that they had received written information about the home, a pre-admission assessment was undertaken and their relative visited the home prior to making a decision about moving in. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 11 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): Standards 6, 7 and 9 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have care plans and risk assessments in place that ensure their needs are met. Residents are supported by staff to lead active and fulfilling lives. EVIDENCE: Two care plans were sampled as part of the case tracking process. Care plans included information in regard to the physical, personal and health care needs, social skills, religious and cultural needs, communication and activities. Aims and goals are recorded. Statutory reviews of care plans had been conducted, and key workers had undertaken three monthly reviews. Care plans used pictures, widget symbols and key words to help residents to understand the contents. One care plan had not been signed by the resident and/or their relative. This was discussed with the manager who stated that this would be attended to. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 12 It was noted that the home is using two sets of care plans, one is kept in the office and the other is known as the working document. The manager informed the Inspector that another system for the care plans is being developed to ensure they are more user friendly for both staff and residents. During discussions, staff were able to give an account of the content of care plans for the residents with whom they key work, and were aware of the need to review care plans. One new member of staff is working along side another key worker with a resident, and is aware of the need to be fully up to date with the contents of the care plans. Staff stated they support residents to make choices about themselves, the clothes they wish to wear, food they would like to eat and daily activities. Staff informed the Inspector that they use pictures that help residents to make choices. Each resident has an allocated key worker who offers one to one support and has a good understanding of his or her assessed needs. During discussions, one parent informed the Inspector that their relative has a care plan that meets their individual needs, they are invited to attend annual reviews, and are kept informed of all events affecting their relative. Risk assessments were observed in care plans sampled. They were regularly reviewed and used picture symbols to help residents understand the meaning of the documents. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 13 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): Standards 12, 13, 15, 16 and 17 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are encouraged by staff to participate in a range of activities both within the home and the local community. A balanced diet is provided for residents. EVIDENCE: Residents living at the home are from different cultural backgrounds, and are cared for by a multi-cultural staff team. The manager informed the Inspector that some residents have chosen not to follow their religion, however, staff do support two residents to practice their religious beliefs. This was confirmed during discussions with staff. One resident’s cultural needs are been supported by the home. Care plans included a list of the activities residents undertake, which include attending a day centre, colleges, art and craft, swimming and shopping. Residents have access to the local community with staff support, and go to the local restaurants, pubs and leisure centre. With the support of the staff, the Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 14 Inspector was able to ascertain from one resident that they like doing the food shopping, going to the cinema, cooking, and having meals out. This resident is looking forward to celebrating their birthday at the weekend, and informed the Inspector that staff are making a special cake, due to their special dietary needs, and relatives and friends will be visiting. Records viewed provided evidence that staff are continually engaging residents in activities inside and outside of the home, that included trips to the cinema, theatre, discos, pubs and shopping. On the day of this site visit the home was very busy transporting residents to their various external activities. Currently, the manager and members of the staff team have to undertake the driving duties. The manager and staff informed the Inspector that the home would benefit from employing a driver. The manager was arranging interviews for this role during this site visit. The manager informed the Inspector that residents are provided with opportunities to meet with other people who do not have a Learning Difficulty through attending college and other external activities. Staff stated they respect residents’ privacy and dignity through knocking on bedroom doors, calling residents by their preferred names and providing personal care in the privacy of their bedrooms and bathrooms. Evidence of these practices was observed during this site visit. The home follows the organisation’s Policies and Procedures in regard to Equality and Diversity, and the sampling of training records provided evidence that staff had received training in regard to this. Throughout the site visit staff were observed to be interacting with residents, supporting as and when required, and allowing them time to make their own decisions. The manager informed the Inspector that there are no restrictions on visitors to the home. This was confirmed during discussions with a visiting parent on the day of the site visit that said that they could visit the home at any time, and they do not have to make appointments to visit. This person was complimentary about the home and the care residents receive from staff. Staff informed the Inspector that regular and daily contact is maintained with residents’ families through daily telephone calls. Staff produce a monthly newsletter that is sent to relatives. This provides information in regard events that have taken place at the home. Residents are able to use the home’s telephone to make and receive telephone calls with staff support, and all receive their own mail. Residents are involved in all daily chores that include helping with the cleaning, washing, laying and clearing the tables, helping to cook the meals and doing Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 15 the shopping. Staff and residents were actively involved in recycling, saving different materials in appropriate containers. Residents are able to spend time on their own if they choose to. This was observed during the site visit, one resident spent some time in their bedroom watching a video. The home uses a four-week menu. The menu includes fresh meat, fish, pasta, salads, fresh vegetables and fruit. The Inspector was able to ascertain from one resident that they liked the food and going shopping to buy it. Staff informed the Inspector that the residents could have a different meal from the day’s menu if they wish. Records of these are maintained in the daily diary, which was viewed by the Inspector. The menu also uses widget symbols, pictures and key words that make it easier for residents to understand the meals being provided. Residents are encouraged and supported by staff to make their own lunches. Three residents have special dietary needs that are being catered for by staff at the home. One resident has their own storage for their food. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 16 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): Standards 18, 19 and 20 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by the home’s storage and administration of medication procedures, however, further attention is required in regard to the recording of some medication. Physical and health care is offered in such a way as to ensure residents’ personal, physical and health care needs are met. EVIDENCE: During discussions, the manager and staff stated that residents require some support with their personal care. Personal support is recorded in care plans, and includes information of how the resident likes to be supported. Staff stated that personal support takes place in the privacy of residents’ bedrooms and/or bathrooms. Care plans sampled evidenced residents are registered with the local GP practice, and have access to a Dentist, Optician, and Chiropodist, and all National Health Services as required. Records of all appointments and annual medical checks are maintained in individual care files. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 17 The home follows the organisation’s Medication Policy and Procedure that was last reviewed in March 2007. The manager informed the Inspector that no current service user is selfmedicating or taking a Controlled Drug. The home uses the Medical Administration Record sheets (MARs) provided by the local pharmacy for the recording of medicines. Each MAR sheet has a photograph of the service user, and specimen signatures of those staff that are trained to administer medication. During discussions staff stated that only those who have received the appropriate training administer the medication. The sampling of training files provided evidence that staff had received training in regard to medication. Medicines are appropriately stored in locked metal medicine cabinets. The manager informed the Inspector that records of medicines received and returned to the Pharmacist are maintained. However, the running totals of two identified medicines had not been recorded on the MAR sheets, therefore it was not possible to follow an accurate audit trail of these medications. A good practice recommendation has been made that running totals of medication must be maintained on the MAR sheets to enable an audit trail to be followed. Evidence found during the site visit supported the information provided in the Annual Quality Assurance Assessment (AQAA). Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 18 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): Standards 22 and 23 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service have access to a satisfactory complaints system that enables residents and their families to raise concerns. Staff having knowledge, training and an understanding of adult protection issues protects the people using the service. EVIDENCE: The Commission For Social Care Inspection has not received any complaints in regard to the care home. The home follows the organisation’s Complaints Policies and Procedures that was last reviewed in March 2007. This document included the timescale for responding to complainants and the correct contact details for the Commission For Social Care Inspection Maidstone office. The home has a complaints/complements book. One complaint had been received by the home since the previous inspection and was satisfactorily resolved. Residents are provided with a copy of the complaints procedure that has been produced using widget symbols and key words. During discussions, one resident informed the Inspector that they would talk to the manager if they were unhappy or feeling sad. Staff stated they are able to tell if residents are unhappy by their body language, behaviour and moods. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 19 One parent informed the Inspector that they knew how to make a complaint, but had not had the need to make one. The home follows the organisation’s Protection of Vulnerable Adults Policy and Procedure that was reviewed in March 2007. It was noted that the policy described the different types of abuse, however, information in regard to Professional Abuse had not been included in the policy. The Proprietor informed the Inspector that this would be included when it is next reviewed in March 2008. A copy of the recent Surrey Multi-Agency Safeguarding Procedures is available in the office for staff to read. During discussions the manager was able to demonstrate an understanding of Safeguarding Adults issues, stating that all concerns would be reported to the organisation, and that the Surrey Safeguarding procedures would be followed. The organisation has a whistle blowing policy. Various scenarios in respect of abusive situations were discussed with three members of staff. They were able to demonstrate an understanding of Safeguarding Adults issues and the procedures to be followed. The sampling of four training files provided evidence that staff had received training in regard to Safeguarding Adults. There is one current ongoing issue in regard to the Protection of Vulnerable Adults. The manager informed the Inspector that the Commission For Social Care Inspection would be notified of the outcome of this investigation. The manager informed the Inspector that residents have individual bank accounts, and the home holds small amounts of money for each resident. The manager informed the Inspector that residents’ monies are checked every day at staff handover time. This was observed during this site visit. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 20 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): Standards 24 and 30 were assessed. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People using the service are provided with satisfactory communal and individual living space making it a safe and comfortable place to live. EVIDENCE: A tour of the communal parts of the home was undertaken, and two residents’ bedrooms were viewed. The accommodation consists of six individual en suite bedrooms, four of these being on the first floor and two on the ground floor. There is no lift access to the first floor. Communal areas consist of a dining room, sitting room and easily accessible kitchen and laundry room. Bedrooms were brightly decorated and included a television, stereo/radio, photographs and residents’ own belongings. Three residents have keys to their bedrooms. Bedroom windows were double glazed and fitted with restrictors to ensure the health and safety of service users is maintained. It was noted that one window Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 21 had condensation in between the glass panes, and a cover from a vent had become loose. The manager stated that this would be reported to the maintenance person for the organisation. Residents had unrestricted access to all communal parts of the home. There is a portable wheelchair ramp that can be used at the front door for residents’ who are wheelchair users. The home took advice from a physiotherapist in regard to having ramps into the back garden. The Proprietor informed the Inspector that the advice was that it would not be practicable to have ramps for access to the garden, instead, it would be acceptable to use the front door and access the garden through the side gate. Currently there are no residents living at the home who use a wheelchair. Communal bathrooms and toilets had liquid soap dispensers and paper towels, however, one bathroom on the ground floor had a hand towel. Although this towel is changed every night, the manager has been advised to write a risk assessment in regard to this. It was noted that the ground floor bathroom had two items of Control of Substances Hazardous to Health (COSHH). A member of staff immediately removed these items. There is a separate laundry room that has two washing machines and a tumble drier. The floor of the laundry is sealed and all Control of Substances Hazardous to Health (COSHH) were kept secure in locked cupboards. The home has a Policy and Procedure in regard to Infection Control. Information provided in the AQAA informs that all staff had attended training in this area. On the day of the site visit the home clean, tidy and free from malodours. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 22 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): Standards 32, 34, 35 and 36 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for staffing are satisfactory, ensuring staff have the qualities and training to meet the needs of the residents. People who use the service are protected by the organisation’s recruitment policy and procedures. EVIDENCE: The manager informed the Inspector that there are currently thirteen staff working at the home. The home works an early and late shift duty rota. There are a minimum of three staff on the early shift and three on the late shift with the exception of Thursdays when there are four staff on the late shift to meet the extra activities taking place. The home currently has one waking night staff and one person covering a sleep in duty every night. Staffing at the weekends is reduced according to the needs and numbers, as some residents go to their relatives for weekends. Information provided in the AQAA, and from discussions with the manager and staff informs that the home exceeds the National Minimum Standards in regard to staff holding the NVQ level 2 and above. One member of staff informed the Inspector that they are due to commence the NVQ level 2 on the week Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 23 beginning 28th January 2008. The sampling of four staff training files provided evidence of NVQ training that had been undertaken. The home follows the organisation’s Recruitment Policy and Procedure that was last reviewed in March 2007. Three staff recruitment files were sampled and each contained the relevant documents as detailed in Schedule 2 of The Care Homes Regulations 2001, however, a photograph and proof of identity for one member of staff could not be located. The manager informed the Inspector that these were obtained from the member of staff concerned when the Criminal Record Bureau and Protection Of Vulnerable Adults (POVA) first checks were applied for, but on the day of the site visit they could not be located. The manager stated this would be attended to immediately. All recruitment files sampled contained POVA first checks. Reference numbers of all staff Criminal Record Bureau checks were maintained in a separate file that is kept secure in a lockable cabinet in the office. The recruitment files require attention in respect of ease of use, and would benefit from having an index in regard to the contents. During discussions staff stated that they had to complete an application form, provide two written referees and had a Criminal Record Bureau check undertaken by the organisation before they commenced working at the home. The sampling of four training files provided evidence that staff are receiving training appropriate to the work they are to perform, which includes Equality and Diversity, Autism, Epilepsy, Challenging Behaviour and Risk Assessments. The manager informed the Inspector that the home does not use restraint, and some staff had attended training in regard to Non Abusive Psychological and Physical Intervention (NAPPI). This focuses on the assessment, prevention and management of unpredictable behaviour. New staff are provided with Induction training. Discussions took place with the manager in regard to training in diabetes. The home has one resident who has this condition, and records of training in this area were not evidenced. The manager informed the Inspector that this was last delivered to staff three years ago, and further training in this area will now be organised. During discussions, one parent informed the Inspector that the staff at the home are very nice, and that they seem to stay which ensures the continuity of care for the residents. Records of staff supervision were viewed on the staff files sampled. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 24 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): Standards 37, 39, 40 and 42 were assessed. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The arrangements for management and administration ensure the home is run in the best interests of residents, and their safety is promoted and safeguarded. EVIDENCE: The manager informed the Inspector that she has had fourteen years experience of management in care homes for adults, and has been the manager of Beech Trees since October 2005. The manager stated that she is a qualified Registered Nurse for Mental Health (RNMH), and completed the Registered Managers Award (RMA) in 2006. The manager stated that recent training she has undertaken includes Epilepsy, NAPPI, Staff Supervision and a Management training course. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 25 Staff informed the Inspector that the manager is supportive, has an open door style of management, and provides formal one to one supervision. Discussions took place with the manager in regard to the reporting of any event that affects the well-being of residents. It was noted that one resident had been to the local hospital’s accident and emergency, however, this was not notified to the Commission For Social Care Inspection through the Regulation 37 Notification. Quality assurance is undertaken through monthly meetings with the residents, minutes of which were viewed during the site visit. Quality assurance surveys had been undertaken to ascertain the views of residents. The manager informed the Inspector that new surveys are to be sent to relatives and other associated professionals to ascertain their views of the care provided by staff at the home. The organisation conducts monthly Regulation 26 visits, and copies of these reports were viewed. The home follows the organisation’s Policies and Procedures that are reviewed on an annual basis. The organisation is committed to ensuring staff are trained to do their jobs. The sampling of staff training files provided evidence that staff are receiving mandatory training as required. Information provided in the AQAA, and through discussions with the proprietor, informed that the organisation is currently having support from an external training agency in regard to undertaking a full analysis of individual staff skills, competences and training needs. During discussions staff stated that they receive regular training, one member of staff stated that the training opportunities provided by the organisation are very good. Staff at the home follow the organisation’s Health and Safety Policies and Procedures that were last reviewed in March 2007. Evidence of staff training in this area was viewed in the training files sampled. Information provided in the AQAA returned to the Commission For Social Care Inspection informed that health and safety records are appropriately maintained and up to date. During this site visit the following records were viewed, annual servicing and monthly testing of the fire alarm systems, fire drills, Portable Appliance Testing (PAT), and daily records of fridge/freezer temperatures. The fire risk assessments viewed had been dated 2005. However, the Proprietor of the organisation contacted the Inspector the day after the site visit and stated that the fire assessments for the home were reviewed in April 2007. These were discussed with the local fire officer at the time of the review. Copies of these risk assessments were forwarded to the local Commission For Social Care Inspection office. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 26 The home undertakes weekly checks on the hot water temperatures, and descales the showerheads on a regular basis. The home has a procedure in place for the prevention of Legionella that clearly states that risk assessments are in place. Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 27 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 3 2 3 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 3 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 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 3 X 3 X 3 3 X 3 X Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action 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. Refer to Standard YA20 Good Practice Recommendations Running totals of medication should be maintained on the Medical Administration Record sheets to enable an audit trail to be followed. A risk assessment should be written in regard to the use of one hand towel in the ground floor toilet. YA30 Beech Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Office 4630 Kingsgate Oxford Business Park South Cowley Oxford OX4 2SU 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 Trees DS0000055261.V356051.R01.S.doc Version 5.2 Page 30 - 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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