Inspection on 13/09/05 for Beauchamp House

This inspection was carried out on 13th September 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beauchamp House 21/06/07

Beauchamp House 29/06/06

Beauchamp House 07/04/05

Beauchamp House 07/10/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Beauchamp House Proctor Road Chedgrave Norwich NR14 6HN Lead Inspector Susan Golphin Announced 13 September 2005, 09:30. th 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 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 Older People. 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. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beauchamp House Address Proctor Road, Chedgrave, Norwich, Norfolk. NR14 6HN. 01508 520755 01508 528646 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Norfolk County Council - Social Services Mr Graham Richard Pollard Care Home 43 Category(ies) of Dementia - over 65 years of age (7), registration, with number Old age, not falling within any other category of places (36) Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Up to 7 service users with dementia and over 65 years of age may be accommodated. 2. Up to 36 older people may be accommodated. 3. The total number not to exceed 43. 4. The rooms below 12 sq metres are not suitable to accommodate wheelchair users at the point of admission. 5. The registered manager will maintain overall responsibility for the care and support of the service users and the management of staff and services of the Homeward Bound Unit. 6. There must be one member of staff on duty at all time with recognised training in dementia awareness. 7. Up to one (1) person under the age of 65 years may be accommodated in the Homeward Bound Unit. Date of last inspection 7th April 2005 Brief Description of the Service: Beauchamp House is a Local Authority Home situated in the village of Chedgrave. Originally built in 1973 and partly upgraded and refurbished in 1995, the home can accommodate up to 43 older people in single rooms (without en suite), on the ground and first floor. 30 service users can be accommodated in the main home and 7 within the separate EMI unit. In addition there is a designated Homeward Bound Unit offering short term rehabilitative support to 6 older people. This unit is an integral part of the residential environment. Part of the garden is enclosed, and offers a discreet and safe environment for service users. There are ample parking facilities to the side of the premises. The home is supported by local GP surgeries and other health services. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This routine announced inspection took place between 9.30am and 3pm, with the Manager Graham Pollard and Care Co-ordinator Jane Sheldrake. All the pre-inspection information and documentation was well presented, clear and submitted on time, and gave a good overview of the homes progress in the previous year to date. The inspection included a brief tour of the premises whilst talking to five staff and four residents and observing the care of four other residents. A small sample of residents care plans and other records relating to staff and residents were also seen. The one comment card which was received by CSCI expressed satisfaction with the service and care and the comments have been included in the report. Feedback on the day was given to Graham Pollard and Jane Sheldrake What the service does well: What has improved since the last inspection? There have been a number of significant changes and improvements in the last year, and the management and staff are commended for their hard work this year. The longer term projects are still work in progress. • • • • Recruitment of staff has improved and seven staff have been appointed recently. A relief post and bank staff are also being recruited as a way to to stabilise the staff group and reduce the use of agency staff. Training at all levels is in place including NVQ 2,3 and 4 training courses. Staff have attended or completed specialist training relating to care of people with dementia and protecting vulnerable adults. Supervision process for staff has been re- established and sessions are taking place on a regular basis. I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 6 Beauchamp House • • • • • Formal staff meetings are also in place and are being planned a year in advance. Care plan format has been revised and is now in use. Senior staff involved in the supervision of staff have received training in appraisal and monitoring procedures. The statement of purpose and service users guide has been updated and amended and is available to residents and their families. The manager and co-ordinators are also continuing to work with staff and with families of residents to promote good levels of communication and contact and encourage involvement and interest in both the care planning and decision making in the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,3 The information about the home and care service provided is in place and available to residents and prospective residents and their families; to enable them to make an informed choice about where they wish to live. There is a satisfactory pre admission process in place. EVIDENCE: The statement of purpose and service users guide was revised earlier this year and has now been distributed and made available to residents. All prospective residents and their families or representatives are provided with the information. The care plan/ assessment process has been revised this year and the preadmission assessment process has provided a basic background of need on which staff have been able to establish a plan of care. The review has identified a need for the home to revise their own process and format in greater detail. ( see recommendation ) Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8 Improvements have been made in the way the healthcare needs of the residents are met, with evidence in the revised and updated care plan which provides staff with the appropriate information to meet residents needs. EVIDENCE: All the residents care plans have been revised and transferred onto the updated format. Five plans were seen and each identified the healthcare needs of the residents and indicated how they will be met. Some information had been supplied by families and by residents themselves, and signed to say they agree with the plan. Not all the care plans have a pre admission assessment of need and those that do are varied in the amount of detail they contain. The management are aware that there is a need to improve their own assessment format which will dovetail with those they receive at the point of referral or admission. It was agreed that monitoring the needs of residents through the homes’ own assessment profile will help in monitoring the dependency level of prospective residents and the appropriateness of each placement. ( see recommendation standard 3). Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 10 Staff confirmed that the information in the care plan provides them with the information they need about residents care. Residents seen on the day said that the staff are supportive and are satisfied with the care they receive. All the staff agreed that they would like to spend more personal time with residents than they are able to because of the overall needs and dependency of the residents. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,15 Social and recreational activities are in place, but there is no consistent process in place which offers personal as well as group stimulation and interest to residents. The meals in this home are good and offer both choice and variety. EVIDENCE: There is a diary of events and activities, some take place on a monthly basis and others weekly. The staff have a good understanding of residents needs and try to offer a personalised activity which is stimulating . There is some item of interest taking place each afternoon excluding Tuesdays when the hairdresser visits. One resident said that they like the bingo sessions and the musical ones. There have been two boat trip outings this year, which proved popular. Care staff said that they are able to give some 1:1 time to residents especially those with special needs, but it tends to be on an ad hoc basis, and can include walking round the enclosed garden, or singalong music sessions. ( see recommendation) The changes introduced to the way the breakfast meal is served has proved to be a success and is to be continued. The changes mean that residents can take their breakfast at a more leisurely pace and close to their own rooms. The menus have recently been reviewed and offer a range of meal choices each day. Residents said of the meals that –‘ they are nice’ and ‘I like old fashioned dinners’ . One of the staff commented on the need to widen the Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 12 choice of meals to those who can only eat softened or pureed foodstuffs to ensure their nutritional intake is maintained. This comment was shared with the management.( see recommendation) Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 The home has a satisfactory complaints procedure in place, and residents have the opportunity to express their views and concerns. EVIDENCE: Residents can express their views or concerns directly to staff and management or at the residents meetings which are documented and any agreed action or activity is confirmed . The management also issue a printed survey leaflet which asks ‘how are we doing’. The complaints procedure and information about the home and services is on display in the reception hall and residents and visitors said that they were aware of the information and how to access it. There have been no formal or informal complaints made this year. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,26 The overall quality and standard of the décor and furnishings of the residents rooms is good and provides and individual and homely atmosphere. EVIDENCE: A brief tour of part of the premises showed that the residents rooms and communal areas are suitably furnished and equipped. The curtains and chairs in the reception hall have recently been replaced and residents were asked to assist in the choice of colour and style. Continence problems identified in small areas of the home are being discreetly addressed. Some of the carpets in residents rooms will be replaced over the next three months. The home is well maintained and the recent acquisition of a steam cleaner is helping to maintain good standards of cleanliness and infection control. One comment received from a visitor suggested the use of dry bacterial gel or spray for hands which could be located in the reception to combat the introduction of any infection from outside the home. This comment was passed Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 15 to the management for consideration. The CSCI acknowledges that this practice is commonplace in some homes and care resources. The manager confirmed that a full review of the premises by Norfolk Property Services is taking place on 15 September 2005 to check on the overall condition of the building and prioritise structural repairs and maintenance. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Increased numbers of permanent staff and greater uptake of NVQ training is improving the consistency and continuity of care in the home. EVIDENCE: Since the last inspection the recruitment drive for the home has been successful and seven more staff have been appointed including relief and bank staff to underpin sudden absences and sickness and reduce the use of agency staff. Agency staff are still being used to meet the shortfall and whenever possible the same staff are used. Residents said that they are happy with the care support they receive. Members of staff confirmed that they have limited time with residents because their individual needs are high and most need a constant level of physical support and supervision. It was also said that there are times in the day when the staffing level is at a minimum and the work load pressures high. From the discussions with staff and from observations on the day the resident dependency is high ( 26 out of 36) have a range of physical and emotional needs , and the registered providers and management should consider reviewing the input of care in relation to the staffing levels especially at crucial times of the day. ( see requirement) Training has been given a high priority this year and the staff who have achieved their NVQ qualifications said that it has added to their confidence and competency. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 17 Seven staff hold NVQ 2 with a further seven in progress. Three staff start NVQ 3 this month and one member of staff commences NVQ 4 also this month and is self funding . Induction and foundation training is in place and the next programme will take place in October 2005. Other training completed this year by staff who work in the main part of the home and staff assigned to the Homeward Bound Unit has included Appraisal / supervision recruitment and selection; medicine management; moving and handling, emergency aid ; basic food hygiene; HIV awareness; understanding dementia; personal care and continence management. 21 staff have also completed fire evacuation training. All the staff working in the Homeward Bound Unit are waiting to complete NVQ3 training in Health and Social Care / promoting independence. The management and registered providers are to be commended for the positive approach to training and the priority given to staff to undertake formal and specialist training in the last year. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 36 The process for supervising staff is in place, and the development and future plans for the home is being communicated to the residents and staff and relatives. EVIDENCE: The supervision procedure for all the staff is in place and staff interviewed on the day confirmed that the formal sessions are taking place. The management acknowledged that they are trying to ensure sessions are not missed, and are monitoring the process and their own presentation and practice. The senior staff have all completed their appraisal training and are more confident about their supervisory role and responsibilities. The management are continuing to develop ways in which communication with residents and their families can be improved to promote openness and better understanding of needs and personal views as well as looking at ways in which general sharing of information and communication can also be improved. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 x 15 3 COMPLAINTS AND PROTECTION 3 x x x x x x 3 STAFFING Standard No Score 27 2 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x x x x x x 3 x x Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 20 no Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 27 Regulation 18 Requirement The registered providers and management must undertake a review of staffing levels to ensure that there are sufficient numbers working in the care home as are appropriate to meet the the health and welfare needs of the residents. Timescale for action immediate and by March 31st 2006 2. 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 3 Good Practice Recommendations It is recommended that the management revue their own pre admission assessment format to compliment that of the placing agency and to ensure the appropriateness of the placement. It is recommended that the management consider ways in which the individual social needs of residents can be addressed so that they can choose between group activities and events and the opportunity to pursue their own interests. It is recommended that the management review and monitor the meal options for those requiring soft or pureed foods to ensure the choices available are wholesome and I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 21 2. 12 3. 15 Beauchamp House nutritional alternatives. 4. Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection 3rd Floor Cavell House St Crispins Road Norwich NR3 1YF National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beauchamp House I55 s35242 Beauchamp House v243119 AN 130905 Stage 4.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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