Care Home: Bells Piece

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What the care home does well Bells Piece offers a homely and friendly environment for its residents. The property is spacious and well furnished, and residents have on-site facilities such as the horticultural and craft centres for their use. The new manager has an honest and open approach and shared with the inspector a number of areas already identified for improvement. She has an action plan in place which is reviewed on a three monthly basis. Staff spoken to were committed and enthusiastic about working at this home. They were very knowledgeable on resident`s needs and were seen to interact well with them. There is an equal opportunities policy in place and staff are given equality and diversity training, especially in relation to disability. Resident`s are supported to be as independent as possible with accessible formats for some policies and procedures, and premises which have been adapted to suit existing resident`s needs. What has improved since the last inspection? All the Requirements and Recommendations made at the last inspection have been met including ensuring all new residents have assessments prior to being admitted, medication records are well kept, and the garden shed is now locked at all times. A new French door has been fitted to the rear of the property. The manager said the Requirement to have an additional lock on the back gate was contested with CSCI as it would restrict service users who used this gate themselves when returning from the park. The meat probe has been tested and is in regular use. Fire records are now kept in one folder and a risk assessment was carried out for radiators without covers. Bedroom doors are now numbered on the fire log to make individual rooms easier to find in the event of an emergency. A new manager has been appointed and a review and action plan drawn up to improve the service at this home. Staff rotas have been reviewed and the manager is consulting staff on suggested new arrangements. The senior care worker has been given responsibility and designated hours to monitor health and safety, including a monthly audit. Training arrangements have also improved, as one member of staff is now responsible for all the administration and record keeping. Work has started on new support plans for residents and a new improved corporate admissions procedure is being piloted at this home. What the care home could do better: Five new Requirements have been made including reviewing written procedures for the protection of vulnerable adults; remedying some decorative shortfalls; checking all recruitment files have the correct information; and ensuring there is sufficient formal and documented staff supervision. It is also required that the home has up-to-date risk assessments in place for the absence of radiator covers (the existing one was out of date), the laundry area, and the vacant room upstairs with no window restrictor. CARE HOME ADULTS 18-65 Bell`s Piece Bell`s Piece Hale Road Farnham Surrey GU9 9QZ Lead Inspector Helen Dickens Unannounced Inspection 25th October 2007 10:45 Bell`s Piece DS0000013567.V346192.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 Bell`s Piece DS0000013567.V346192.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. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bell`s Piece Address Bell`s Piece Hale Road Farnham Surrey GU9 9QZ 01252 715138 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) bellspiece@south.leonard-cheshire.org.uk www.leonard-cheshire.org.uk Leonard Cheshire Post Vacant Care Home 13 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (1) of places Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be: 12, 30-60 years and 1 over 65 years 9th May 2006 Date of last inspection Brief Description of the Service: Bells Piece is a large detached house that has been converted to provide a care home for younger adults with learning disabilities operated by the Leonard Cheshire Foundation. The home is located in attractive grounds at the end of a private driveway on the outskirts of Farnham. There are local shops and other amenities close by. Sharing the grounds of the home is a Horticultural and Craft Centre which service users have the opportunity to work in. The home is spacious and offers mostly single bedroom accommodation on both floors, one with en-suite facilities, some with small kitchen areas and others are self contained flats including one shared flat. There are a variety of communal rooms on the ground floor. The home has car-parking facilities for several cars. Fees currently start at £519 per person per week. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection was unannounced and took place over 7 hours. The inspection was carried out by Helen Dickens, Regulation Inspector. The new manager and team leader represented the establishment. A partial tour of the premises took place. The inspector spoke to four residents and one visitor on a one-to-one basis, and talked briefly with several other residents during the day. In addition to the new manager, four members of staff were also spoken with. Five questionnaires returned to CSCI prior to this inspection were also used in writing this report. Two resident’s care plans and a number of other documents and files, including three staff files, as well as risk assessments and maintenance records, were examined during the day. The Annual Quality Assurance Assessment completed by the home prior to the inspection has also been used in writing this report. The Commission for Social Care Inspection would like to thank the residents, relatives, new manager and staff for their hospitality, assistance and cooperation with this inspection. What the service does well: What has improved since the last inspection? All the Requirements and Recommendations made at the last inspection have been met including ensuring all new residents have assessments prior to being admitted, medication records are well kept, and the garden shed is now locked Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 6 at all times. A new French door has been fitted to the rear of the property. The manager said the Requirement to have an additional lock on the back gate was contested with CSCI as it would restrict service users who used this gate themselves when returning from the park. The meat probe has been tested and is in regular use. Fire records are now kept in one folder and a risk assessment was carried out for radiators without covers. Bedroom doors are now numbered on the fire log to make individual rooms easier to find in the event of an emergency. A new manager has been appointed and a review and action plan drawn up to improve the service at this home. Staff rotas have been reviewed and the manager is consulting staff on suggested new arrangements. The senior care worker has been given responsibility and designated hours to monitor health and safety, including a monthly audit. Training arrangements have also improved, as one member of staff is now responsible for all the administration and record keeping. Work has started on new support plans for residents and a new improved corporate admissions procedure is being piloted at this home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective resident’s individual needs and aspirations are assessed before they move into Bells Piece. EVIDENCE: Two resident’s files were sampled. One resident had been there for many years and their original assessments had been archived. However, more recent reviews and assessments for the last six years were kept on their current file and were satisfactory. The second resident who had been admitted more recently had an assessment by the home and the care manager’s assessment on their file. The assessments were sufficiently detailed to enable the home to draw up a care plan, and there was good evidence that residents had been involved in this process. There were no negative issues raised by residents, relatives or healthcare professionals in relation to needs being met. There was a Review at the home on the day of the inspection and at the end, the resident reportedly told the care manager that they were ‘very contented’ at Bell’s Piece. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s needs are reflected in their individual care plans, and they are encouraged to make decisions and take risks as part of an independent lifestyle. EVIDENCE: Two care plans were sampled and found to contain a good level of detail in relation to resident’s personal, health and social care needs. Plans were regularly reviewed and signed by residents. The first page of each plan has a widget/easy word format, to make it more accessible to residents. The manager has reviewed the current format and is introducing a more personcentred approach, with an even more accessible format to fully involve residents in their care planning. Any resident over the age of 65 will need their care plan reviewed on a monthly rather than six-monthly basis to meet the National Minimum Standards for Older People, and this was discussed with the manager and team leader who said they would implement this immediately. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 10 Residents at this home are encouraged to make decisions in their daily lives and there was plenty of evidence of residents being encouraged to be independent. Information is given to residents to assist them in their decisionmaking. For example, residents choose between them what they would like on the menu for the coming week. To help them make healthy eating decisions, a laminated card has been created outlining healthy options in pictures and easy words. Residents all have their own bank accounts and are supported to do their own banking. When asked on a questionnaire what the service does well, one health professional wrote ‘individual empowerment’ of residents. There are many examples of residents being encouraged to take risks as part of an independent lifestyle. Residents were seen to be doing their own laundry, preparing meals, and snacks, and one was answering the front door bell and getting people to sign in. One resident travels alone on public transport to visit a relative in the West Country, and goes into the local town centre independently. Risk assessments are on file for each resident, for example in relation to self-administration of medication. Some additional general risk assessments are needed at this home and these are discussed under Standard 42. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15 and 17 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents at this home have opportunities for personal development and to take part in a wide range of activities. They take part in local community activities and family and friendship links are encouraged. Residents are offered a healthy diet, which they are involved in preparing themselves. EVIDENCE: Life skills training is available for residents at this home and there were good examples of how residents had been supported to become independent in relation to meal preparation, managing their own finances, and going out into the local community. There are educational opportunities available for those who wish to take part including computing, drama and arts and crafts. One resident does voluntary work and others take part in the on-site horticultural and art studio activities. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 12 Opportunities for leisure activities include ad hoc events, for example the planned Halloween party, and the use of the games room. Some residents belong to clubs locally, including one who has joined a day centre in town for older people. Resident’s photographs in the front hall showed the holiday destinations in 2007 including one group who had gone to Greece, and another group to Turkey. Residents told the inspector about how they had enjoyed their holiday, including one who had learnt to swim to enjoy the hotel pool on the Turkish holiday. The home supports resident’s family and friendship links and staff were knowledgeable about resident’s social networks. One resident is supported to visit a relative in the West Country with staff preparing advice on timetables and travel. One relative who completed a questionnaire made a number of positive comments about this home including, in answer to the question ‘What does the home do well?’, they wrote ‘Everything possible.’ Daily routines at this home promote independence, with many residents being responsible for some of their own meals, including doing food shopping for these, and for their own laundry – some have a washer and tumble dryer in their room. Staff were respectful to residents at all times, they knocked on doors before entering, and residents had unrestricted access to the home, signing in and out so that staff would know whether they were in. There were no instances of staff interacting with each other whilst excluding residents; indeed there were many instances were staff stopped what they were doing in order to include a resident who had approached them. Resident’s at this home have a good deal of independence in relation to meals, and one key worker described a resident as almost ‘half-board’ as they shopped for food and prepared all their own breakfasts and lunches. Some residents have snack making facilities and kitchenettes of their own. Residents were observed to make themselves drinks in the main kitchen, and to help with communal meals. On the day of the inspection one resident was preparing a salad to go with the pizza for supper. Healthy eating options are encouraged and the menu contains a number of homemade meals. Residents choose the meals at the beginning of each week and this then generates the shopping list. Residents and staff have the main evening meal together and residents do the washing up. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents receive support in the way they prefer and require and their health needs are met. The home’s arrangements for the administration of medication promote independence and protect residents. EVIDENCE: Care plans at this home identify how residents wish to be supported and are signed off by each resident. One key worker interviewed was very knowledgeable about the personal and healthcare needs of the client she worked with. For example, for some aspects of their personal care the person was completely independent, and for others they needed supervision and guidance. Those residents spoken to all had their own individual dress styles and their appearance reflected their personality. One resident showed the inspector some very pretty jewellery she was wearing and told the story of where this had come from. Resident’s health needs are recorded on their files and there were very good records of appointments with healthcare professionals, and the outcome. Resident’s are supported to use local health facilities and the home has a good Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 14 working relationship with local health professionals. One healthcare professional who returned a questionnaire to CSCI ticked that the care staff always have the right skills and experience to support individual’s social and healthcare needs. One resident had had a poor experience at the local hospital and their key worker enabled the resident to raise this matter as a complaint to the relevant authorities. The team leader takes responsibility for medication and it is very well organised. Some residents are self-medicating and have risk assessments in place and their own locked cabinet in their room. There is a medication policy in place, laminated and displayed in the medicines room. Medicines are kept securely and only those who have had medication training are allowed to administer medicines to residents. The medication cabinets were checked and found to be well ordered and clean, and two resident’s records were sampled and found to be satisfactory, with no unexplained gaps. A note of basic side effects has been made for staff, and the GP has signed off the use of homely remedies for individual residents. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s complaints would be listened to and acted upon. People who live at this home are protected from abuse, though more work needs to be done on the corporate policy to fully safeguard residents. EVIDENCE: The home has a complaints procedure in place and a user-friendly version for residents. There have been no complaints received in the last year about this home to CSCI. The manager said there have been no complaints to the home either. At Leonard Cheshire homes, all complaints have to be notified to the regional office and a monitoring form is completed – this ensures that all complaints are followed up appropriately. There were no negative issues raised on the questionnaires retuned to CSCI in relation to complaints, and professionals who deal with this home said any concerns they had raised were responded to appropriately. The home uses the corporate protection of vulnerable adults policy, and have a copy of the local Surrey multi-agency procedures in the office. As a result of an issue being raised last year in relation to protection, all staff, volunteers and residents have had a half-day vulnerable adults training session provided by Surrey social services. A letter was then sent out to all staff, by the general manager, reminding them of their responsibilities in relation to this matter. The manager and one staff member interviewed were knowledgeable about what action to take in the event of suspected abuse. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 16 However, the corporate policy needs reviewing to ensure it is clear that all instances of suspected abuse be reported to the Surrey local safeguarding contact number. The policy itself does not dovetail with the Surrey policy and it is recommended that a policy specific to this home be developed, which is more accessible to staff (the corporate policy is 14 pages in length including the forms). The policy also does not make it clear that disciplinary measures (e.g. suspension of staff) may be necessary in some circumstances. Resident’s finances are safeguarded at this home. All residents are supported to set up their own bank accounts where PIN numbers are not needed. This means resident’s can go to the bank themselves (some are supported by a care worker for the journey) and carry out their own transactions. Money is not held in the office for residents, and all have a lockable cabinet in their rooms to keep any money and valuables. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Bells Piece offers a well-furnished and homely environment for residents, though some decoration and refurbishment is needed. The home is clean and hygienic, with just one area needing some attention. EVIDENCE: Bells Piece offers a homely environment with very comfortable furnishings and fittings. The dining room has one large and one small solid wood table and chairs and matching dresser, offering a very pleasant dining facility. The living room and separate games room are also well furnished with comfortable sofas and chairs, and leisure opportunities for residents including games, videos, computer, and a flat screen television. Three resident’s bedrooms were visited and found to be very personalised reflecting each resident’s hobbies and interests. Some residents have a kitchenette and laundry facilities of their own. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 18 The manager said she is doing a feasibility study on refurbishing the whole property which has a number of areas which need decorating and up grading. Shortfalls such as a large patch of paper off an upstairs wall and the stairs to the top floor which need redecorating were discussed with the manager. The food store downstairs needs a brush and the shelves need wiping. An upstairs window in a vacant room had no window restrictor, and this is covered under Standard 42 at the end of this report. The home is clean, pleasant and hygienic and there were no offensive odours. Staff and residents do the cleaning between them with residents doing their own rooms were possible. The laundry was visited and found to be clean and tidy, with a washable floor, and sufficient washers and dryers for the home. There is a laundry basket for bath mats which are washed after every single use. Some resident’s have their own private laundry facilities and do their own laundry with support from staff as needed. All hand basins in communal areas had individually dispensed soap and paper towels. There should be a written risk assessment for the laundry as there were liquids and powders in the cupboard, and this is a Requirement under Standard 42. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 19 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 and 36 People who use the service experience adequate outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents are supported by competent staff though more work needs to be done to ensure at least 50 of care staff hold NVQ qualifications. Recruitment arrangements also need more work to fully protect residents. Induction and training arrangements continue to improve at this home, though the current system for staff supervision must be improved. EVIDENCE: Staff are respectful towards residents and during the inspection there were many instances of good communication between residents and staff. One key worker was interviewed and demonstrated an excellent knowledge of the needs of the residents she worked with including techniques for promoting independence. One member of the care staff who was not a key worker but worked with all residents, was also very knowledgeable on the needs of different residents in relation to their meals and nutrition. Currently the home do not have at least 50 of care staff qualified to NVQ Level 2 or above as set down in Standard 32. The new manager said she has recently registered more staff on this course as it had already been identified Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 20 that they were not up to the recommended numbers. She has also identified that the current rota system does not give sufficient flexibility for the deployment of staff or identify who the shift leader will be when the senior staff are off duty. She is currently consulting with existing staff to improve these arrangements. Two staff recruitment files were sampled during the inspection. There were records of interviews, application forms and references, as well as CRB and pova checks on file. One member of staff taken on last year had been given an application form requesting only a ten-year employment history, rather than a full employment history as set out in the Care Homes Regulations 2001 (as amended). As this member of staff was on duty, they were able to supply their own full employment history for the file. The service has since changed its application form but will need to look back to ensure all those taken on since July 2004 have the necessary full employment history. Some of the difficulty lay in the lack of clarity about who, the human resources department or the service, was responsible for making sure each file had the appropriate information and that any checks (e.g. gaps in employment history), had been followed up. The general manager, who joined the inspection briefly in the afternoon, was made aware of these matters and said he would ensure they were remedied. One recruitment file for a volunteer was checked and found to have a satisfactory CRB and pova check, as well as a good record of training provided by Leonard Cheshire. The manager was reminded that volunteers must have the same checks and information on file as paid staff, and as set down in Schedule 2 of the Regulations. The manager meets weekly with the team leader and this was confirmed by looking back in her diary – however, these sessions are not documented in a central place and therefore it is difficult to ascertain whether the six regular recorded supervision sessions per year, set down in Standard 36 have been met. There were three such documented sessions on file for the last 12 months. The new manager has already identified a shortfall in the frequency of supervision for staff, mainly because the existing rota makes it difficult to get the relevant staff on duty at the same time. She is currently reviewing staff supervision arrangements and was clear that at least six sessions per year of formal, documented supervision must be given to all staff. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use the service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Resident’s benefit from a well run home and can be confident their views are taken into account. The health, safety and welfare of residents is promoted but more work must be done to ensure there are appropriate risk assessments in place at all times. EVIDENCE: A new manager was appointed in June 2007 though she had already worked at the home as a locum alongside the previous manager. She has 16 years management experience in the care sector, the last five of these as a locum manager for Leonard Cheshire. She has a City and Guilds in Advanced Management for Care. The new manager has responsibility for the budget, implementing policies and procedures of the care home, and ensuring they comply with the Care Standards Act and Regulations. She was open and Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 22 honest during discussions about the review she had carried out and actions already taken to remedy any shortfalls found in this service. However, the manager has not yet started the registration process with CSCI and is still at the stage of completing her CRB application. The post is a ‘service manager’ role and gives the post holder equal responsibility for the care home, day services, the horticultural centre, and for community services run from this site. The job description does not specify the minimum number of hours that are dedicated to the care home, nor could this be easily calculated from the new manager’s diary. The service may need to review these arrangements and issues raised with the manager will be passed on to the CSCI central registration team who will be expecting the candidate to demonstrate that they have sufficient time and resources at their disposal to manage this home effectively. There are a number of quality assurance measures in place at this home and residents are encouraged to have input into all aspects of their daily lives. There are monthly resident’s meetings and in addition the manager makes time to sit down for supper with residents on a regular basis. There are Regulation 26 visits on behalf of the provider, and there are service user surveys carried out by the organisation. The entire service has been reviewed this year and an action plan is in place to address any shortfalls and improve the service for residents. Consultation on a number of aspects of this plan are currently underway with residents and staff. The new manager was asked to consider an in-house questionnaire for residents, as the current questionnaire goes to all Leonard Cheshire service users and therefore feedback specific to Bells Piece is not available. One senior member of staff has taken overall responsibility for health and safety. She was interviewed briefly by the inspector and found to be knowledgeable on the arrangements already in place. She has time off the care rota to carry out a monthly audit and any risk assessments. The regional health and safety officer also does an annual inspection, and the regional safety adviser carries out the fire risk assessment. The reports have action plans and staff have to respond to the regional office under the existing followup procedure. In the last report there were a number of health and safety issues raised. There is now a risk assessment in place regarding the absence of radiator covers, though this needed up dating and perhaps more detail than on the earlier version. The manager said they have been given some radiator covers and would be fitting these over the coming weeks, prioritising those radiators which potentially carried more risk. However, residents at this home are all fully mobile and fairly independent and the overall risk is deemed by the service to be low. The staff member responsible for health and safety said the recommendation regarding the meat probe has now been met. In addition, the recommendation to have numbers on bedroom doors in case of fire has been Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 23 met by the fire log having resident’s names and a number, whilst bedroom doors just contain their name. The laundry area must have a documented risk assessment in place, as must the vacant room upstairs (to be kept locked) where there is no window restrictor. Bell`s Piece DS0000013567.V346192.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 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 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 3 X X 2 X Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA23 Regulation 13(6) Requirement Timescale for action 25/11/07 2. YA24 23(2)(b) 3. YA34 19(1)(b) The corporate policy on the protection of vulnerable adults must be reviewed as discussed with the new manager and general manger during the inspection, and as set down under Standard 23 in this report. 25/11/07 The following environmental shortfalls must be dealt with in a timely fashion: • A large patch of paper which has come off an upstairs wall • The stairs and landing to the top floor need redecorating • The food store downstairs needs a thorough clean The registered person must 25/11/07 not employ a person to work at the care home unless he has obtained the information and documents specified in paragraphs 1-9 of Schedule 2 of The Care Homes Regulations 2001 (as amended). Files must be checked retrospectively to DS0000013567.V346192.R01.S.doc Version 5.2 Bell`s Piece Page 26 4. 5. YA36 YA42 ensure the specified information has been sought. 18(2)(a) Staff must be appropriately 25/11/07 supervised. 13(4)(a)(b)(c) Up-to-date risk assessments 26/11/07 must be in place for the following: • The absence of radiator covers • The laundry area • The vacant room upstairs with no window restrictor. 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 YA23 Good Practice Recommendations It is recommended that a safeguarding adults policy, specific to this home, be developed. It should be accessible to staff and be able to be used by them as a quick reference guide. Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 27 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 Bell`s Piece DS0000013567.V346192.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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