Care Home: Bewsey House

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What the care home does well There is a good system to introduce new people to the home. Time and effort is spent making sure that they are familiar with the home before they move in. They receive the information they need to help them make an informed choice and have their needs assessed so they know that the home is suitable to meet their needs. The principles of privacy and dignity are promoted at the home so the people who live there feel respected and valued. Equality and diversity is promoted through person centred planning so people receive care and support in the way they prefer. The home is managed by an experienced and qualified manager so staff receive the support, leadership and guidance they need and operate as an effective team. The staff are experienced, trained and skilled so the people who live at the home know they are in safe hands. What has improved since the last inspection? The home`s care planning systems have been improved. They are more centred on the person rather than just their needs so people are helped to live fulfilling lives and receive support in the way they prefer. The medication systems used in the home have been improved. Stock records for loose medicines have been introduced to make sure that people who live in the home always receive their medication correctly and their health care needs are met. The people who live at the home have been asked about improvements they would like to be made there and their views have been acted upon. A new games room has been provided and partitioning and screens have been provided to improve privacy in the main lounge. Some of the communal areas of the home have been redecorated and new furniture has been provided in the main lounge so people live in homely and comfortable surroundings. What the care home could do better: People who are in intending to move in to the home should be given a statement of terms and conditions or contract before the day they move in so they have enough time to think about the terms and conditions and can ask for things to be clarified if necessary. Assessments of a person`s capacity to make a decision should only be done if there is any doubt that the person is unable to make that particular decision. This is to make sure that people`s rights to make decisions are always respected and promoted. People`s needs for social interaction, education and leisure opportunities should be reviewed and where appropriate reassurance given so they are helped to do the things they like doing and to lead fulfilling lifestyles. CARE HOME ADULTS 18-65 Bewsey House 8 Bewsey Road Bewsey Warrington Cheshire WA7 2LW Lead Inspector David Jones Key Unannounced Inspection 25 September 2008 09:50 Bewsey House DS0000027000.V367214.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 Bewsey House DS0000027000.V367214.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. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bewsey House Address 8 Bewsey Road Bewsey Warrington Cheshire WA7 2LW 01925 414961 01925 636485 bird984999831@aol.com 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) Warrington Community Care Susan May Brown Care Home 18 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (18), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (18) Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home is registered for a maximum of 18 service users to include: * * No more than eighteen service users of either sex aged 40 to 65 years with mental disorder excluding learning disability or dementia in the category (MD) are accommodated. No more than eighteen service users of either sex aged 65 years or over with mental disorder, excluding learning disability or dementia in the category (MD(E) are accommodated. 2 People who present with mobility problems may only be accommodated if the layout of the home is suitable for them and appropriate facilities and services are available to meet their needs. 13 September 2006 Date of last inspection Brief Description of the Service: Warrington Community Care, a registered charity, runs Bewsey House. The home is registered with the CSCI to provide care and support for 18 people aged 40 years who have mental ill health. There are 18 single bedrooms on two floors, one large and three small lounges, a dining room, kitchen and laundry. There is a lift to the first floor and there are pleasant and wellestablished gardens at the back of the home. The premises have been adapted over the years but are not suitable for people who need a lot of help to move around. The home is within walking distance of Warrington town centre with access to shops, public transport and local amenities. Information about Bewsey House including copies of the most recent inspection report is made available to each person who lives at the home and their representatives and can be acquired by contacting the manager on 01925 414961. Fees range according to the needs of the individual and accommodation they occupy from £347 to £395 per week. There are no additional charges other than sundry items charged at cost. Bewsey House DS0000027000.V367214.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 stars. This means the people who use this service experience good quality outcomes This key inspection was unannounced. The visit to the home took place on one day; it started at 9:50 in the morning and lasted over nine hours in total. The visit was carried out by David Jones, regulatory inspector, and Amanda Wells an “Expert by Experience” took part in the inspection. An ‘Expert by Experience’ is a person who, because of their shared experience of using services, and/or ways of communicating, visits a service with an inspector to help them get a picture of what it is like to live in the home. This visit was just one part of the inspection. Before the visit took place we (the commission) asked the manager to complete a questionnaire that we call an annual quality assurance assessment or AQAA for short. It gives us information about how the home is meeting the needs of the people who use the service and includes future plans for further development. We made survey questionnaires available for the people who live in the home and the staff. Their views about the home have been taken into account in this report. We also looked at the information that we already had about the home and this with the information from the AQAA helped us to form our inspection plan. Records of three people who live in the home were checked to see the care they receive. Some people were spoken with and their views taken into account. Some of the home’s policies and procedures were also checked. What the service does well: There is a good system to introduce new people to the home. Time and effort is spent making sure that they are familiar with the home before they move in. They receive the information they need to help them make an informed choice and have their needs assessed so they know that the home is suitable to meet their needs. The principles of privacy and dignity are promoted at the home so the people who live there feel respected and valued. Equality and diversity is promoted through person centred planning so people receive care and support in the way they prefer. The home is managed by an experienced and qualified manager so staff receive the support, leadership and guidance they need and operate as an Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 6 effective team. The staff are experienced, trained and skilled so the people who live at the home know they are in safe hands. What has improved since the last inspection? 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. Bewsey House DS0000027000.V367214.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 Bewsey House DS0000027000.V367214.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): 1, 2, 3, 4, and 5 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There is a good system to introduce people to the home, with information provided and needs assessments done, so they know that their needs can be met at the home. EVIDENCE: People who are interested in moving to Bewsey House are provided with a statement of purpose and service users guide so they have the information they need to make an informed choice about the home’s suitability for them. The statement of purpose and service users guide contain information about the home including the philosophy of care, facilities and services provided. People are also given copies of past CSCI inspection reports and the home’s quality assurance reports, which include the views of other people living at the home. This is to help them with their decision-making. The service users guide is illustrated with symbols and pictures to make the information easier to understand. Most of the people living at the home said that they had enough information about the home to help them decide about moving in, but one person who had moved in recently told us they had not seen the service users guide before. The manager told us that staff go through the service users guide with people when they first move in and after Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 9 that if people ask them to. Staff should consider whether people have understood the information and if necessary go through it with them again so they are reminded. People who are thinking about moving in are encouraged to visit the home before making a final decision about moving in, so they know it is suitable to meet their needs. We looked at the care records for three people who lived at the home and we asked people about their personal experiences of moving in. We could see that a lot of time and effort was spent making the process of moving in personal and sensitive to the needs of each person. For example, one person told us that they had got used to the home over a long period of time and made many visits before they decided it was the right place for them. Another person told us that they wanted to move in straight away so they only made one visit and moved in shortly after. Records showed that people have their needs assessed by qualified and experienced staff from the home before they move in so they are sure that their needs can be met there. With the permission of the person, information about the needs and personal preferences of each individual is gathered from a range of sources including health and social care professionals and, where appropriate, family members. In this way each person’s diverse needs are recognised and recorded so care staff have the guidance they need to provide care in the way the person prefers. All of the people who live at the home are asked to sign and agree a “license” agreement. This confirms the terms and conditions on which care and accommodation are provided so they know their rights and responsibilities. The manager explained that staff go through the license agreement with the individual on the day they move in. We would recommend that this is done before the day the individual moves in so they have enough time to reflect on the terms and conditions and seek clarification about them if necessary. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, and 9 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who live at Bewsey House are involved with the development of their individual care plans so they receive the care and support they need in the way they prefer. EVIDENCE: People who live at Bewsey House are involved in the planning their own care and support so they are helped to maintain control of their lives and develop a lifestyle that reflects their needs and personal goals. Two of the care plans we read were detailed; they covered all aspects of the individual’s life including their health and social care needs and personal preferences. This had positive outcomes for each person. The two people concerned told us that they were very happy at the home and they received appropriate levels of care and support to meet their needs. The third care plan we read was for a person who had moved in to the home the day before our visit to the home. It provided some basic information but Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 11 did not cover all their needs and had not been agreed with them. However, enough information about their needs had been gathered during the assessment and staff were working with the person to develop care plans that would meet their personal needs and preferences. Risk assessment is at the centre of the home’s assessment and care planning processes. Managers and staff understand the importance of people being supported to take control of their own lives, and to encourage and enable them to exercise their rights and make their own decisions and choices. There were many examples where people were being helped to manage risk so they could live a more fulfilling lifestyle, including going out into the local community, taking part in activities and social events. Records showed that staff had taken action to reduce risks so people were safe in doing this. Some staff had attended training on the Mental Capacity Act. A new assessment document was being used to help them make an assessment of a person’s capacity to make a specific decision. Some of these had not been done properly and staff might need further guidance to make sure that people’s rights to make decisions for themselves are protected. In some circumstances where hazards to health or personal injury of the person or others had been identified, limitations on their freedom of movement or power to make decisions had been put in place in the interests of safety. For example, where a risk assessment had identified that a person was unable to extinguish cigarettes safely, they were asked to give their lighter and cigarettes to staff so their smoking could be supervised. The manager told us that any limitation that had been put in place had been agreed with the person but there was no written evidence of this. People had not been asked to sign their risk assessments and goal plans, so there was no written evidence to confirm their agreement. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who live at Bewsey House are able to make choices about their lifestyle and receive support so they can develop their life skills and lead more fulfilling lifestyles. EVIDENCE: We spoke with six of the people who lived at the home about opportunities for leisure, recreation and personal development. Some people told us that they were very happy with the home and the facilities and services provided. For example, one person told us how staff had helped them to explore and take advantage of opportunities for recreation, leisure and education. They were living a lifestyle that met their expectations and were achieving their goals for personal development. However, other people told us that they often felt bored, lacked stimulation and on some occasions felt isolated in the home. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 13 Records showed that the home provides a range of opportunities for people to take part in social, recreational and leisure activities inside and outside of the home. The manager showed us that people are consulted about what they would like to do at small group meetings but there is often a lack of interest in chosen activities. Managers and staff understand the importance of helping people to achieve their goals, follow their interests and be integrated into community life in the way the person wants. They recognise that people who live at the home have diverse and differing needs and this is reflected in each person’s care records. Staff told us that they try to make sure that appropriate arrangements are made to support each person but they had experienced difficulty helping some people to identify the support they need to live the lifestyle they would wish. The manager gave an example where they had made arrangements to support one person on a one to one activity but the person refused the activity when it had been offered on a number of occasions. The manager said it was clear that the person had wanted to do the activity but there was something that prevented them from taking part that they could not express. The expert by experience told us that there are times when people want to do things but feel unable to the take the initial step often because of mental distress, lack of confidence or feelings of unworthiness. They suggested one way to help people to develop their confidence and ability to take part would be to reassure them that they will be offered a range of interesting activities inside and outside of the home until such time as they are ready to take it up. The home has a key worker system. Some people told us that they would like more one to one support from staff but they do not always feel able to ask for it. The manager told us that she was aware that additional staff are needed from time to time and will review each person’s care plan to make sure that all are offered appropriate levels of one to one support. Records show that staff support people to maintain family links, friendships and personal relationships. They are able to entertain their guests in private if they wish. Visitors were made welcome. Records of meals served showed us that a varied and nutritious diet is provided. Some people told us that they liked the meals but others said the food was bland. The people who live at the home are involved in planning and developing menus. The manager was able to show us that people’s suggestions, likes and dislikes had been acted upon. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs so they receive personal care in the way they prefer and in a way that shows respect for their privacy and dignity. EVIDENCE: People living at the home told us that their health care needs are met and they are always treated with dignity and respect. They are encouraged to manage their own health care and are helped to make and maintain contact with their health care professionals. They are able to choose their own GP and have access to all NHS facilities in the local community. Personal health care needs, including specialist health care and dietary requirements, are clearly recorded in each person’s person centred plan. Care records provide an overview of each person’s health care needs and show any changes in their health needs. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 15 We checked the medication records and these showed that the people who live at the home received appropriate levels of support with their medication so their health care needs were met and their independence is promoted. There were some minor recording errors on stock records but these were easily corrected and the manager produced an action plan to prevent this happening again. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. There are good procedures so people who live in the home are able to express their concerns and be listened to, their rights are protected and they are safeguarded from abuse. EVIDENCE: The complaints procedure is available to the people who live at the home and to other interested parties or professionals on request. No complaints had been received by the home since our last inspection in 2006. In addition, we have not received any complaints about the home since then. People who live in the home are given a copy of the complaints procedure that sets out how to make a complaint and the action that will be taken by the home in response. Most of the people we spoke with and all those who sent us back completed surveys confirmed they knew how to make a complaint. However some people told us they did not know how to make a complaint and some told us that staff do not always listen and act on what they say. The manager told us that some of the people who live at the home have difficulty reading and understanding documents written in a standard format so staff will go through any document with them when they first move in and at any time afterwards if they ask. Staff should consider whether people have understood the information and know how to make a complaint. If necessary they should go through the complaints procedure with them again so they are reminded. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 17 We recommend that complaints procedure is produced in a variety of formats, such as large print, a picture or audio version so all people are helped to understand the information about how they can make a complaint. There are thorough procedures for responding to suspicion or evidence of abuse or neglect, including whistle blowing so staff can raise concerns and make sure that people are protected. There has been one adult safeguarding referral from the home in the last 12 months. This problem was reported to the local authority and managers and staff have worked in partnership with the social services department to make sure people are safeguarded. Information in the AQAA told us that all staff had received training in adult safeguarding so they know what to do if they are become aware of any evidence or suspect that any of the people living at the home is being abused. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, and 30 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well maintained so people live in comfortable, clean surroundings that meet their needs. EVIDENCE: Bewsey House is in a residential area of Warrington with easy access to the local shops and general amenities. The home is well maintained with good quality furnishings and fittings. It is set in its own grounds and there are gardens for people who live there to enjoy. The communal areas of the home have been redecorated and new carpets and furniture has been provided. The home has been running for a long time and is designed to meet the needs of 18 adults living together as a group of people. The home has a lift to the first floor but some corridors are narrow and other aspects of the home restrict access for people with physical disabilities. We spoke to some of the people who live at the home about the layout and they told us they liked the home the way it is. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 19 The manager had responded to a recommendation made at the last inspection to explore how the home could be improved. People were asked whether they would like a “residents’ kitchen” to be provided so they would have opportunity to practice domestic skills including food preparation and cooking. Records showed that some people were interested in this but the majority opted for a games room instead. One of the lounges on the first floor had been converted to a games room with pool table and other games. Other improvements included fitting blinds to the office door and providing two partition screens to improve privacy for people using the main lounge. The home is clean and well maintained throughout. All people responding to our survey said the home is always clean and fresh. One person we spoke with told us “the home is kept spotless”. Systems are in place for food hygiene and infection control so people are protected from infection and food contamination. Maintenance records show that electrical and gas installations, the lift and fire prevention equipment are serviced regularly so people living in the home are safe Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, and 36 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The people who live at the home are supported by well trained, effective staff who have gone though a thorough recruitment process, so people’s needs are met and they are safe from possible harm or poor practice. EVIDENCE: We observed staff work as an effective team. They were clear about their roles and responsibilities. They carried out their work with good humour, sensitivity and respect for the people who live at the home. Staff rotas show that there is always a minimum of two staff on duty throughout the daytime. At nighttime there is one staff member on wakeful duty and one senior member of staff sleeping in on call. The people who live at the home told us that they enjoy good relationships with the staff and one person said the staff were brilliant and were always there for them. We could see that there were enough staff to meet peoples’ immediate health and personal care needs but some people told us they needed to spend more time with staff on a one to one basis and one person said they sometimes feel they are left to their own devices. The manager told us that limited staffing Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 21 resources were a barrier to improvement. They said that staffing levels were only just adequate to meet the health care and social needs of the people who lived at the home and much more could be done if there were more staff available to help people with activities. The manager should review staffing levels to make sure that the home is always staffed sufficiently to meet the personal care, health care and social needs of all the people who live at the home. Where unmet needs are identified that cannot be met within the home’s resources, this should be discussed with the person and their representatives, including the social services department, so appropriate action can be taken to make sure the person’s needs are fully met. We talked to the manager and some staff about staff training opportunities and we looked at staff training records. All new staff benefit from thorough induction procedures including Skills for Care common induction standards. These set down minimum expectations about learning needed so new care workers know how to work safely and effectively. More than 70 of the staff have or were working towards National Vocational Qualifications at level 2 or 3 in health and social care. One person is working toward NVQ level 3 in health and social care. All staff have an annual appraisal, which helps them and their managers to identify further training needs. Staff told us that they had received training and regular updates on adult safeguarding, moving and handling, medication, and mental health awareness. Some staff had done additional training on equality and diversity, Mental Capacity Act and person centred planning. Both cooks had experience and qualifications in catering including food hygiene. We checked the staff recruitment for the only staff member recruited since our last inspection and we discussed recruitment procedures with the manager. Records show that the home’s recruitment procedures are thorough so people who live at the home are safe and protected from harm and abuse. All care staff were cheerful, friendly and helpful. They told us they were well supported and appreciated the leadership and guidance provided by the manager and other senior staff. Records show that all care staff receive formal one to one supervision regularly. Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well managed so that it is run in the best interests of the people who live there. EVIDENCE: The manager is experienced in the field of mental health and has achieved the Registered Manager’s award and an NVQ level 4 in care. Staff speak highly of the manager saying she is a good manager, a good listener and very supportive. The quality assurance procedures for the home are based on seeking and acting on the views of the people who live at the home. Feedback is actively sought from people who live at the home, relatives and health and social care professionals about the standard of support, care; facilities and services Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 23 provided. This is done by annual survey questionnaires and by monthly quality audits conducted by the care co-ordinator. The findings of the home’s quality assurance processes are published in quality summaries so the people who live at the home know their views are taken seriously. However there is no indication in the most recent quality assurance summary of action taken to address issues raised. This is important so people know that their views are acted upon. Warrington Community Care seeks to ensure the health and safety of all the people who live and work at the home. There is a health and safety policy that confirms individual and management responsibilities for managing health and safety and ensuring safe working practices. The manager ensures that risk assessments are carried out for all safe working practices; significant findings are recorded and reviewed so staff and people who live at the home are safe. Routine maintenance checks are carried out on all appliances and services. Precautions are taken against the risk of fire including routine fire drills and fire awareness training for staff and people who live in the home so they know what to do in the event of a fire Bewsey House DS0000027000.V367214.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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X 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 X Bewsey House DS0000027000.V367214.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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA5 Good Practice Recommendations People who are in intending on moving in to the home should be given a statement of terms and conditions or contract before the day they move in so they have sufficient time to reflect on the terms and conditions and seek clarification if necessary. A review should be done about capacity assessments to make sure these are carried out only when there is doubt about a person’s capacity to make a specific decision so they help staff identify the level of help an individual may need to make a certain decision. Any limitation placed on an person’s freedom of movement or power to make decisions in the interests of safety should be agreed with the individual and their agreement recorded to make sure their rights are promoted. 2 YA7 3 YA7 Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 26 4 YA12 Staff need to continue to work with the people who live at Bewsey House to help them gain the confidence they need to take part in social activities. The complaints procedure should be produced in a variety of formats, which may include large print, picture and audio versions so all people are helped to understand the information should they need to make a complaint. Staffing levels should be reviewed to make sure that the home is always staffed sufficiently to meet the social needs of all the people who live at the home. Information about the action taken to deal with quality issues raised should be included in the home’s quality summary reports so people will know their views have been acted upon. 5 YA22 6 YA33 7 YA39 Bewsey House DS0000027000.V367214.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Region CSCI Preston Unit 1 Tustin Court Port Way Preston PR2 2YQ 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. 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