Care Home: Belstead Villa

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What the care home does well The interaction between staff and people that lived at the home was respectful, friendly and professional. People’s views and choices were listened to and their preferences were clearly identified in their care plans. The home was clean and attractively furnished. People’s bedrooms were large and provided en suite and kitchenette facilities, which encouraged their independence. People were provided with the opportunity to participate in activities in the local community which were of interest to them. The manager had a clear understanding of their role and responsibilities and they were aware of the areas that they needed to improve on in the home. What has improved since the last inspection? This is the first key inspection of a new service, therefore no areas for improvement were identified.Belstead VillaDS0000073103.V375451.R01.S.docVersion 5.2 What the care home could do better: At the time of the site visit we were aware that the provider had not paid the required annual fees to CQC (Care Quality Commission). The provider had been informed that legal action would be considered if payment was not made. People’s contracts were not available in the home for inspection. The manager told us that they were in the organisation’s head office and they assured us that copies would be kept in the home to ensure that they were available for people that lived at the home to view if they chose to. However, we were informed that contracts had been provided to people or/and their representatives. There were some areas in the home’s maintenance that needed attention, such as cracks in the wall and a shower that leaked. The manager told us that the home was under the builder’s warranty and a date had been booked for the builders to return to the home and make good the areas that needed improvement. The laundry was in the basement and was not fit for purpose. The manager told us that they had identified that the laundry provision needed to be addressed and had discussed the problems with the provider. There were some areas of improvement, such as the Statement of Purpose needed to be updating to include CQC (Care Quality Commission) details, more detailed medication guidance needed to be developed and consideration to be made about how the staff at the home recorded compliments that were received by the service. The manager was aware of the areas of improvement and assured us that they would be actioned in a timely manner. At the time of the inspection we noted that the issues identified had not adversely affected the outcomes for people that lived at the home. Key inspection report CARE HOME ADULTS 18-65 Belstead Villa 52 Belstead Road Ipswich IP2 8BB Lead Inspector Julie Small Unannounced Inspection 18th May 2009 12:45 Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belstead Villa Address 52 Belstead Road Ipswich IP2 8BB 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) 01473 786620 www.concensusupport.com Consensus Support Services Ltd Mr Adrian John Hedges Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Learning Disability - Code LD The maximum number of service users who can be accommodated is 4 2. Date of last inspection This is a new service Brief Description of the Service: Belstead Villa was registered with Commission for Social Care Inspection November 2008. The home provides support to four young adults with learning disabilities. The support provided includes the transition to adulthood and the development of their independence. On the site there is also a children’s home which is registered with Ofsted. The home is situated on a residential road which is within walking distance to Ipswich town centre. Ipswich provides various shopping, public transport and recreational facilities. At the time of the key inspection the manager told us that the fees for the home were £1,960 per week. Belstead Villa DS0000073103.V375451.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 2 star. This means the people who use this service experience good quality outcomes. The unannounced inspection took place Monday 18th May 2009 from 12:45 to 18:45. The inspection was a key inspection, which focused on the core standards relating to adults and was undertaken by regulatory inspector Julie Small. The report has been written using accumulated evidence gained prior to and during the inspection. The manager was present during the inspection and the requested information was provided promptly and in an open manner. During the inspection health and safety records, staff training records and the recruitment records for three staff were viewed. The care records of two people that live at the home were tracked, which included care plans and medication records. Further records viewed are detailed in the main body of this report. Observation of work practice was undertaken, four people that lived at the home were met and two were spoken with. Two staff members were spoken with. Prior to the inspection an Annual Quality Assurance Assessment (AQAA) was sent to the home and it was returned to us in the required timescales. Staff and service user surveys were sent to the home. One service user and three staff surveys were returned to us before the inspection. What the service does well: What has improved since the last inspection? This is the first key inspection of a new service, therefore no areas for improvement were identified. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 6 What they could do better: If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Belstead Villa DS0000073103.V375451.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 Belstead Villa DS0000073103.V375451.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 5 People using 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 can expect to be provided with the information that they need to make decisions about where to live, to be provided with a detailed needs assessment before they move in and that their assessed needs and preferences are met. EVIDENCE: People were provided with information about the home in the Statement of Purpose and the Service User’s Guide, which clearly identified the support and service that they could expect, should they decide to move into the home. A service user survey said that they were asked if they wanted to move into the home and that they had been provided with enough information about the home before they moved in so that they could decide if it was the right place for them. The Statement of Purpose was viewed and included details such as the registered provider, the qualifications and experience of the manager, the training and qualifications of the staff team, the aims and objectives of the service, the service that was provided at the home, fire safety and a summary Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 9 of the complaints procedure. The contact details of CSCI were detailed in the document, which needed to be updated to show the contact details of CQC, should people wish to contact us. The AQAA stated ‘Belstead Road’s Statement of Purpose was developed December 2008’ and ‘the individual is provided with a statement of purpose and young persons guide’. The Service User’s Guide was viewed and it was noted that it was in picture and text format, which was accessible to the people who used the service. The Service User’s Guide included the details of the service and support that were provided at the home, such as that people’s choices were listened to and respected and the provision of activities both in the home and in the community. The care records of two people that lived at the home were viewed and each held a local authority needs assessment and a needs assessment which had been undertaken by the home’s management team before they moved into the home. The care records held a detailed care plan which identified how their assessed needs and preferences were to be met. The AQAA stated ‘work is carried out with the commissioning team to ensure that adequate and detailed information is received about a potential new young person. An assessment, or review is carried out and the county allocation policy guides the process’. People’s contracts were not available in the home for inspection and the manager told us that they were stored at the organisation head office. The manager said that they were aware that a copy should be kept in the home and assured us that this would be addressed. It was noted that this shortfall did not adversely affect outcomes for people living at the home at this time. People and/or their representatives had been provided with a copy of their contract The AQAA stated ‘individuals will have up to date individual charters and service user agreements which detail their rights and responsibilities, the fee that is charged, conditions of the home, termination of contract, support that will be given and the complaints procedure. Individual plans support the service users to promote and increase their independent use of daily living skills and to assess their needs and aspirations. This includes use of specialised services where appropriate’. Belstead Villa DS0000073103.V375451.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 People using 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 can expect to have their needs and preferences set out in an individual care plan, to be supported to take risks as part of an independent lifestyle, to be supported to make decisions about their lives and that confidentiality of information that is kept about them is maintained. EVIDENCE: The care records of two people that lived at the home were viewed and they held a detailed care plan, which identified how their assessed needs and preferences were met. Each care plan held a document which had been signed and dated by staff to show that they had read and understood the care plan. The care plans detailed the support that people needed and preferred in areas such as their personal care, behaviour, communication, relationships, sexuality and mobility. The care plans clearly detailed the areas of people’s daily living Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 11 that they could attend to independently and how their dignity was respected. People’s care plans that were viewed held detailed risk assessments, which identified the risks in their daily living and the methods of minimising the risks. The risk assessments included areas of people’s activities and using facilities in the community and in the home. There were some areas of positive support that had been provided to a person who had displayed self harming behaviours. The AQAA stated ‘the staff team will undertake ongoing training in risk assessment and where possible, young people will be supported to take reasonable risks to fulfil their ambitions. Risk assessment is used to enable experience rather than prevent activity. The staff at Belstead Road know the young people well and will be competent at supporting and meeting individual’s needs’. The manager told us that the care plans were working documents, which would be improved over time and that they planned to improve the care plans to ensure that they were more person centred. The AQAA stated ‘clear individual care plans will be negotiated with individuals to identify preferred ways of being supported and to help improve independence and young people’s understanding of their right to make their own choices. Staff will sign to indicate that they have read and understood the document and the competence of new staff is assessed and their portfolio signed by the manager’. The staff survey asked if they were provided with up to date information about the people that they supported. Two answered usually and one answered always. Three staff surveys said that the ways that they passed on information about the people who used the services between staff usually worked well. Staff that were spoken with told us that the care plans detailed how they were to meet people’s needs. They showed a good understanding of people’s individual needs. A staff member told us that they were a person’s key worker and explained their role in ensuring that the care plans were up to date and that they detailed people’s changing needs and preferences. People’s records that were viewed showed that the care plans were reviewed on a monthly basis and regularly updated when changes in their needs and preferences had arisen. The AQAA stated ‘each individual will have a designated key worker and co-key worker who maintains regular reviews on all support plans to ensure development on independence and communication is maintained effectively. There will be active involvement from family members on a regular basis and both service users and their families understand the role of their key worker. Family, education providers, day service key workers and people from other external agencies will be invited to an annual lifestyle review where the needs Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 12 and aspirations of the young person will be discussed. Changes requested by the young person will be documented and plans are available in accessible versions’. Two people that lived at the home were spoken with told us that their needs were met, that they chose what they wanted to do and that the staff listened to them. A service user survey said that they sometimes made decisions about what they wanted to do each day and that the carers listened and acted upon what they said. Daily records that were viewed showed how people had made choices each day, observations by staff of their well being and the support that they had been provided with. During the inspection we observed people making decisions about what they wanted to do, such as their chosen evening activity. People who used communication methods other than spoken English were supported equally by staff and a staff member assisted us in communicating with a person who used Makaton sign language. Staff training records that were viewed and staff that were spoken with confirmed that they were provided with Makaton training, which showed that people’s diverse communication needs were met. The AQAA stated ‘all the young people will have the opportunity and are actively encouraged to express their choices on a daily basis in all areas of their lives using their individual communication strategies. Individuals are encouraged to participate in the day to day running of Belstead Road and their ideas are sought about the ongoing development of the service mainly through informal discussions at meal times and regular residents meetings’. The minutes from resident’s meetings were viewed, which showed that people participated in making choices about the home, such as activities, décor and meals. The AQAA stated ‘where possible, young people will be given the opportunity to be involved with staff interviews and always have the chance to meet any new staff before they are offered the post. This gives the opportunity for the young people to ask any questions they may have’. During the inspection we observed that people’s confidentiality was respected. During our discussions with staff members and the manager about the support that they provided to people, they ensured that doors were closed to ensure that we could not be overheard. When we spoke with people that lived at the home they were asked if they preferred for staff to leave the environment or if they wished for them to remain for support. People’s personal records were stored securely in the home. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 13 The AQAA stated ‘issues of confidentiality will be respected within guidelines. Young people will be supported to understand they can speak to any member of staff in confidence and this will not be passed on unless there is a risk of harm. They will be supported to understand that sometimes information must be passed to the manager, but that their family will not be informed unless they wish for them to be. Staff will ensure this is communicated effectively each time the need arises’. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 14 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): This is what people staying in this care home experience: 12, 13, 14, 15, 16, 17 People using 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 can expect to be provided with the opportunity to participate in activities which are of interest to them, to be supported to maintain the contacts that they choose to, to be treated with respect and to be provided with a balanced diet. EVIDENCE: The care records of two people were viewed and they clearly detailed people’s daily routines, which included their attendance at school, college or day centre and how they travelled to their placement, such as by taxi. The manager told us about a person that attended school and the work that they were undertaking to support the person to seek an appropriate and more local adult placement, this was clearly documented in their records. A person was spoken Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 15 with and told us about the day centre that they attended which they regularly attended, which they travelled to by taxi. People were provided with the opportunity to participate in activities that were of interest to them in the home and in the local community. The care records that were viewed clearly identified people’s preferences with regards to activities and the activities that they had participated in. During the inspection people were engaged in discussions with the staff team regarding their chosen visit to the cinema. A person told us that they had chosen the film which they were going to watch, that the cinema was close to the home and that they would be walking to the cinema. The person told us that they chose the activities that they were interested in and that they visited a local pool club. A person was spoken with and told us about their holiday that was planned for the week of the inspection. They were going on an overseas holiday with two staff members where they were meeting with their family. We viewed a detailed folder, which identified the plans for their holiday and the decisions that the person had made. The folder included photographs of the accommodation and a clear plan for the holiday. The AQAA stated ‘staff practice will be consistent to enable development of communication skills on all levels using collections of photos and objects of reference. In house activities and community engagement will be maintained by a wide variety of choices being offered. External planned activities are supported using public transport and community services such as the local sports centre, cinema, shopping in the local town, days out to theme parks and other city centres. Individuals choose will be supported in where they go and who with’. A person showed us their bedroom and it was noted that there were several items which they could use for leisure, which included a television, music centre and pool table. People’s records that were viewed identified the contacts that they chose to maintain with family and friends and the methods of maintaining the contacts, such as visits and telephone calls. During the inspection we observed a staff member speaking to a person’s relative on the telephone where they planned the travel arrangements for a future visit. The AQAA stated ‘relationships with family and friends will be actively maintained by Belstead Road staff. Young people will regularly have visits home, including overnight stays, meals out, phone calls and visitors at their home’. Interaction between staff and people that lived at the home was observed to be friendly, respectful and professional. The staff included people in all their conversations. Staff were observed to call people by their preferred form of Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 16 address, which was clearly identified in their care plan. People that were spoken with told us that the staff treated them with respect and that their privacy was respected. They said that staff always knocked their bedroom doors before entering. The AQAA stated ‘staff and young people will respect peoples need for privacy, by knocking on bedroom doors and waiting for a response before entering. People will have the opportunity to choose whether or not to have their own front door key and each bedroom door has a lock available’. People were supported to maintain their independence in the home, which included washing their laundry and cleaning the environment in which they lived. The laundry in the home was not safe for people to use and there was an additional laundry area in the grounds, which people could use. The AQAA stated ‘people will be actively involved with the daily running of their home. Individuals help to maintain the cleanliness of their bedrooms and their personal laundry. Household tasks will be chosen by the young people to complete throughout the week and each person will have the chance to help cook the evening meal on a pre-planned evening. Feedback is paramount before, during and after any task or activity’ and ‘where possible, young people will be given the opportunity to be involved with staff interviews and always have the chance to meet any new staff before they are offered the post. This gives the opportunity for the young people to ask any questions they may have’. People told us that they cooked meals at the home and we observed a person who was supported by staff in the preparations for the evening meal during the inspection, which was a roast chicken dinner. The AQAA stated ‘the person cooking will have the opportunity to choose the evening meal based on individual preferences and dietary needs. Alternatives are available for people who prefer something different. Breakfast, lunch and snacks are chosen by people at a time which suits them. Meals are generally cooked from fresh and fresh fruit and vegetables are always available. Support will be provided for monthly take away and theme nights’. The menu was viewed and it was noted that people were provided with a balanced and healthy diet. A person showed us their bedroom, which held a kitchenette area where they could make drinks and prepare light meals and snacks. It was noted that there were clear risk assessments of the person’s use of the kitchenette area, which identified how the assessed risks were to be minimised. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 17 Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 People using 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 can expect to be provided with the personal support that they prefer and require, to have their health needs met and to be protected by the home’s medication procedures. EVIDENCE: The care plans of people that lived at the home which were viewed clearly identified how their preferences and assessed needs were met with regards to their personal care. The records showed the areas of their personal care which they could attend to independently. The AQAA stated ‘young people will be supported to get up at a time which suits their needs. Individuals choose their own time to go to bed and when to get up at weekends. Each young person will have key worker who works closely to ensure they receive the appropriate level of support’. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 19 The care plans which were viewed identified the health care support that people were provided with to meet their needs, which included the outcomes from appointments such as with the doctor, dentist and hospital. There were clear records of psychological support that had been provided by CAMHS (Child and Adolescent Mental Health Support) team and there were areas of good practice which had supported a person with their behaviour. The AQAA stated ‘appointments with other professionals will be made promptly which include optician, chiropodist, dentist, GP when needed and with the consultant. Staff will act promptly when medical problems arise using local GP and primary care facilities or the national Drs on-call system’. The manager and a staff member were spoken with and told us that they had recently attended a training course on the Mental Capacity Act and that they were booked to attend a course on Depravation of Liberty, which they needed to ensure that they were working as they should be. People were protected by the home’s medication procedures and processes. The medication storage was viewed, which was securely stored in a metal cabinet in MDS (monitored dosage system) blister packs the office and the controlled medication was stored appropriately. The manager told us that the local pharmacy had provided advice regarding the required storage facility for controlled medication. There was a secure medication refrigerator in the office which ensured that medication that should be refrigerated was done so. The manager was asked if they maintained regular temperature checks of the room to ensure that medication was stored at the correct temperature. They agreed that this would be addressed. The AQAA stated ‘all medication will be stored in a locked cabinet in the office. Weekly checks are carried out promptly by Belstead Road staff and a quarterly check will be carried out by the manager on three occasions and a manager from another service on the fourth. Staff are familiar with the protocol for any incidents regarding missed, refused, or damaged medication. Medication will be ordered monthly by requesting prescription from the GP. There is a clear process for the administration of medication’. The administration records for controlled medication were viewed, which was in an appropriate book and it was noted that a running total of the controlled medication was maintained. A person was prescribed PRN (as required) medication for their behaviour. A staff member told us that they had not used the medication since the person had moved into the home and that they had been provided with training on supporting people with challenging behaviour, which supported the staff to divert the person’s behaviours. The manager agreed that although the PRN medication had not been used, they would ensure that clear guidelines would be produced which would identify the points Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 20 of the person’s behaviour that the medication would be considered and administered. The MAR (medication administration records) charts were viewed and it was noted that the administration of medication was clearly recorded. However, it was noted that there were two gaps in one person’s MAR charts. The communication book was viewed and it was noted that the discrepancy had been identified in a timely manner and the staff had been advised staff that the medication must be signed for as it was not present in the MDS blister pack, which indicated that it had been administered. It was noted that where medication had not been administered the appropriate codes were used, for example if a person was on leave and the reasons for the non administration were also detailed on the rear of the MAR chart. The AQAA stated ‘individual recording sheets state dosages and times for taking medication (MAR sheets) and are signed to signify that the correct medication has been checked and administered’. A staff member was observed administering medication to a person at tea time, it was noted that they removed the medication from the MDS blister pack directly into a clean pot and the MAR chart was signed when they had observed the person taking their medication. They were observed recording the medication delivery that was received during the inspection. They showed us the records that were maintained which showed when people had taken their medication on home leave, which showed that the medication was accounted for. The staff member told us that they had been provided with medication training and they had an understanding of their role and responsibilities regarding the safe handling of medication. The AQAA stated ‘all staff will receive core training in administering medication and do not undertake this task until the training has been completed and the member of staff considered capable’. The staff training records that were viewed confirmed that they were provided with medication training. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 21 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 People using 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 can expect to have their complaints listened to and acted upon and to be protected from abuse. EVIDENCE: People that lived at the home were protected from abuse and self harm. The care records of a person were viewed and it was noted that there were some good practice regarding self harming behaviours. During the inspection we viewed a safeguarding alert that had been forwarded to the local authority safeguarding team by the home’s manager following an allegation made by a person that lived at the home. The manager had forwarded a notification regarding the incident to CQC, which was received. The issue was clearly recorded and it showed that people were listened to and that concerns of abuse were acted upon in a timely manner. Incident and accident records were viewed and they clearly identified the support that had been provided to people with their behaviour. Where injuries had been identified, they were clearly investigated and recorded on body charts which were maintained in people’s records. The staff were provided with information regarding to the safeguarding of Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 22 people in the home’s safeguarding procedures, the local authority safeguarding guidelines, adult safeguarding training and child protection training. The AQAA stated ‘Consensus operates clear procedures for people to raise any concerns relating to harm including a whistle blowing policy. The service manager is responsible for implementing policies including the POVA (protection of vulnerable adults) and safeguarding children procedure guidelines under which any abuse or allegation of abuse is reported. This ensures a rapid and multi-agency approach’. People were provided with information about how they could complain about the service that they were provided with in the home’s detailed complaints procedure was viewed, which was summarised in the Statement of Purpose and Service User’s Guide. The complaints procedure was additionally provided in a picture and text format, which was accessible to the people who lived at the home. A service user survey said that they knew how to make a complaint. Three staff surveys said that they knew what actions to take if a person wished to make a complaint about the service that they were provided with. There had been one complaint received by the home. The complaints records were viewed and it was noted that the issue was acted upon and investigated in a timely manner. The AQAA stated ‘young people will be supported to understand that they have the right to speak to any member of staff about any concerns they have. This will always be done in private in their bedrooms, or a quiet place of their choosing. Staff will work closely with the young people to read their body language and facial expressions and use communication aids when necessary’ and ‘there is an effective complaints procedure in place, available in accessible versions. Both young people and their families are aware of the procedure and who to contact in the event of a complaint’. We asked the manager about how they planned to record compliments, they agreed that they would consider how this would be addressed and assured us that the compliments made about the home would be recorded. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 23 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 27, 28, 30 People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People can expect to live in a home which is homely and clean, however they cannot be assured that they can freely access all areas of the home. EVIDENCE: The home was situated on a residential road near to Ipswich town centre. At the rear of the home there was a children’s home. The home had been converted to provide self contained bedrooms/flats for up to four young people and communal areas. The communal areas included two lounges, kitchen/dining room and attractive gardens. There was also a building, ‘the loft’, in the grounds in which people could use to do their laundry independently. The AQAA stated ‘the loft is an external building which is being developed with an IT area, quiet area and domestic kitchen to help develop life Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 24 skills’. The communal areas were clean and attractively furnished and decorated. It was noted that there no unpleasant odours in the home. A service user survey said that the home was always fresh and clean. During a tour of the building it was noted that there was a crack in the wall in the hall. We asked the manager about the plan for maintaining the environment. The manager told us that the home was still covered by the builder’s warranty and that they had booked to return to the home to address the issues in the environment which had been identified, such as the cracks in the wall and that the shower in one person’s en-suite had leaked. The AQAA stated ‘a high standard of cleanliness is maintained by both staff and young people, with a planned programme of maintenance which includes substantial input from night staff’. The manager told us that the home provided a maintenance worker who undertook minor repairs in the home and the maintenance records were viewed, which identified the areas for repair and when they had been completed. A person showed us their bedroom, which included a living area, a kitchenette and en-suite facilities, which included a toilet, hand wash basin and shower. The room was personalised and reflected the person’s choice and personality. The AQAA stated ‘each individual’s bedroom is decorated in accordance with their preferences and has a bed, a bedside table, a wardrobe, a chest of drawers, ensuite facilities, and fully equipped kitchen, own phone. Each person’s room has a stereo/CD/ TV. Carpets and soft furnishing can be chosen by the individual. Each room has under floor heating, central lighting and each door is lockable if required. Young people can if required, purchase their own furniture with staff support’. There was no bath in the home to provide people with a choice of bathing facilities. The manager told us that this may be provided in the future if people’s choices reflected that this was what they wanted. The laundry was situated in the basement of the home, the laundry was not accessible to the people who lived at the home. To access the laundry there was a steep staircase with a low ceiling, which provided access and manual handling risks to staff when they were transporting laundry up and down the stairs. The flooring in the laundry was not impermeable, which did not allow effective cleaning and the floor was damp. The damp had spread to the bottom stairs which had buckled the stair covering. The laundry was small and did not provide clean and dirty areas. There was a washing machine, a drying machine and hand washing facilities to minimise the risk of cross infection. The laundry and toilets provided hand wash liquid and disposable paper towels Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 25 which minimised the risk of cross infection. The AQAA stated ‘staff have been trained in infection control and food hygiene and are aware of Consensus Policies and Procedures relating to the control of infection’. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 26 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35 People using 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 that use the service can expect to have their needs met by a competent and trained staff team and to be protected by the home’s recruitment procedures. EVIDENCE: People were supported by a competent staff team to meet their needs. The home had met the target of 50 staff to have achieved a minimum of NVQ (National Vocational Qualification) level 2 as identified in the National Minimum Standards relating to adults. A training matrix that was viewed also showed that staff had various qualifications which related to the people that they supported, such as two staff members had achieved a diploma in learning disability nursing. The AQAA stated ‘NVQ training is offered to all staff and a reward system is in place as an incentive to encourage take up. Different learning styles are catered for with different organisations available to provide Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 27 training’. The training records of staff that were viewed showed that they were provided with the Learning Disability Induction Framework (LDIF), which ensured that they were advised on the specific support that was required by the people that lived in the home. The staff survey asked if their induction covered everything that they needed to know to do the job when they started and three answered very well. The AQAA stated ‘personal care cannot be undertaken until a member of staff has gone through all the clearance procedures, and completed core and induction training. A three month probationary process will be in place with appraisal due at this time’. Staff that were spoken with told us that they were provided with a good training programme which supported them to meet the needs of the people that lived in the home. Three staff surveys said that they were provided with training which was relevant to their role, helped them to understand and meet people’s needs and kept them up to date with new ways of working. The training certificates and a training matrix was viewed and training courses that were provided included adult safeguarding, child protection, medication, first aid, infection control, conflict management, health and safety and first aid. The AQAA stated ‘all staff attend training early in their employment delivered by an internal trainer to ensure they are trained to CIS level and are assessed by managers whilst undergoing a period of shadowing another member of staff for a specified period of time within the service’ and ‘annual appraisals will identify individual training needs and personal development plans and identify how these are met during the year and are reviewed during supervision’. During the inspection it was observed that staff interacted with people that lived at the home in a friendly, respectful and professional manner. The AQAA stated ‘young people at Belstead Road will develop a positive rapport with all members of the staff team and the staff will get to know them well. Staff will be supported to display confidence when working with individuals and become committed to their job, demonstrating active listening skills and action to support choice, opportunity and independence’. The recruitment records of three staff members were viewed and it was noted that the appropriate recruitment checks were made to ensure that people were safeguarded. The records included a CRB (Criminal Records Bureau) check, POVAfirst (protection of vulnerable adults) check, a work history, identification and two written references. Three staff surveys said that the appropriate checks were undertaken before they started work. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 28 The AQAA stated ‘Consensus has a comprehensive recruitment and selection procedure which is inclusive of the people we support and meets the requirements of all relevant legislation. Interviews will be divided into two stages with the initial stage being formal interview and the second stage with the young people. This ensures that the young people have the opportunity to meet with potential staff and raise any concerns they have with staff prior to a conditional offer being made. Conditional offers are made subject to clearance from CRB, POVA, POCA, medical, work permits and references’. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 29 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42, 43 People using 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 can expect to live in a home which is well managed, run in their best interests and to have their health, safety and welfare promoted and protected. EVIDENCE: The home’s registered manager was successful in the CSCI registered manager application process November 2008. The manager had attended several training courses which included Professional Certificate in Business Management, employment law essentials, protection of vulnerable adults, health and safety for managers, first aid, fundamentals of management, administration of medication, food hygiene, infection control, dealing with Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 30 challenging behaviour and risk and conflict management. The manager was spoken with and told us that they had commenced the registered manager award in their previous employment and that they were due to complete the award in the near furture. The manager provided a good understanding of their roles and responsibilities as the registered manager of the home. The home was run in the best interests of the people that lived there. They were consulted with about the care and support that they were provided with in their care plans and resident’s meetings. People that were spoken with confirmed that their choices were listened to. People were further consulted with about their views of the service that they were provided with in the monthly Regulation 26 visits. The Regulation 26 visit reports were viewed and showed that the running of the home was monitored. People’s health, safety and welfare was protected, which was shown in the health and safety records that were viewed. The records included PAT (portable appliance testing) check, gas safety certificate, monthly environmental health and safety checks, nurse call bell checks, water temperature checks, pandemic flu guidelines and the home’s disaster plan. Regular fire safety checks were undertaken and there was a fire risk assessment in place. The AQAA stated ‘regular health and safety reviews will be carried out to ensure checks are being completed and any issues are being dealt with effectively. Monthly walking routes are carried out to ensure the maintanence and cleanliness of the home is maintained to a high standard. Health and safety certificates are checked to ensure they are in date’. Staff training records were viewed and it was noted that staff were provided with health and safety training, such as infection control, safeguarding and first aid. The AQAA stated ‘finances are primarily co-ordinated by the finance manager and area manager to ensure maintenance of viability of the service. These are supported by Consensus and local negotioations with comissioners will be held with the home manager with input from the finance department’. The registration report for the home November 2008 stated ‘ the financial reference is clear and the business plan submitted was for the provider, Consensus Support Services and demonstrates a well-run, financially sound company that is able to ensure the continuation of this service if there were any difficulties in the future. The business plan is clear and demonstrates the long-term strategy for the development of this care service. On discussion with the officers of the company, present at the site visit to the service on 20th November 2008, they were able to demonstrate an adequate understanding of the financial concerns of running this service’. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 31 The manager was spoken with during the inspection and they told us that there were no issues with obtaining money from the providers for the day to day running of the home. Annual fees payable to CQC had not been paid and the provider had been informed by letter that we would consider legal action as a result of non-payment. Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 32 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 3 4 X 5 2 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 3 27 3 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 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 3 X 3 X X 3 2 Version 5.2 Page 33 Belstead Villa DS0000073103.V375451.R01.S.doc Are there any outstanding requirements from the last inspection? No, this is a new service 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. Refer to Standard Good Practice Recommendations Belstead Villa DS0000073103.V375451.R01.S.doc Version 5.2 Page 34 Care Quality Commission Eastern Region Care Quality Commission Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. 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