Inspection on 21/06/07 for Beauchamp House

This inspection was carried out on 21st June 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 29/06/06

Beauchamp House 13/09/05

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 Norfolk NR14 6HN Lead Inspector Mr Pearson Clarke Unannounced Inspection 21st June 2007 10:00 X10015.doc Version 1.40 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 Beauchamp House DS0000035242.V344079.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 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 DS0000035242.V344079.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beauchamp House Address Proctor Road Chedgrave Norwich Norfolk NR14 6HN 01508 520755 01508 528646 beauchamphouse@norfolk.gov.uk www.norfolk.gov.uk Norfolk County Council-Community Care 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) Mr Graham Richard Pollard Care Home 43 Category(ies) of Dementia - over 65 years of age (7), Old age, registration, with number not falling within any other category (36) of places Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Up to 7 service users with dementia and over 65 years of age may be accommodated. Up to 36 older people may be accommodated. The total number not to exceed 43. The rooms below 12 sq metres are not suitable to accommodate wheelchair users at the point of admission 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. There must be one member of staff on duty at all times with a recognised training in dementia awareness. Up to one (1) person under the age of 65 years may be accommodated in the Homeward Bound Unit. 29th June 2006 6. 7. Date of last inspection 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. The current fee levels for the home are individually assessed with a maximum weekly charge of £368.72. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers outcomes for people using the service. The key inspection of this service has been carried out by using information from previous inspections, information from the providers ,the residents and their relatives, as well as others who work in the agency. This has included a recent unannounced visit to the agency and this report gives a brief overview of the service and current judgements for each outcome. In respect of this report the late return of the services Annual Quality Assessment meant it was not possible to survey service users and other interested parties and judgements made have been formed from a narrower base than would normally be the case. What the service does well: What has improved since the last inspection? Staffing levels and the organisation of staff on duty have been improved allowing for more effective care delivery. The general standard of assessment and care planning has improved during the last year allowing for better admissions and clearer guidance for staff working with residents. The service has introduced nutritional care planning to help ensure that dietary needs are properly met. The provider has sought specialist advice relating to design for people with dementia and redecorated the specialist unit using colours suggested. A successful funding application has been made which will allow for redevelopment of this unit’s gardens over the next year and again specialist advice has been incorporated into the scheme Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 6 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. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. That improved assessment and better staffing levels have helped assure prospective residents that their needs can be successfully met on admission. People using the re-ablement unit continue to benefit from an effective service. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the last year the provider has submitted regulation 26 visiting reports which paint a picture of the service. Information gained from these reports shows the service to be working on improving care planning and assessment. During the site visit, recent admissions were tracked and the service’s approach in this area was discussed with the service manager. The inspector found a more robust and appropriate admission and assessment system to be in place , with evidence that recent admissions were appropriately made. Increases in staff hours and reorganisation of the rota have also helped the service meet the assessed needs of the people accommodated. Time was spent in the re-ablement unit with the inspector looking at care records and talking to the member of staff on duty and the one service user Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 9 present. Based on this it could be seen that the service continues to achieve very good results, with the vast majority of people admitted from hospital able to successfully go home again. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is good. That the home uses its care planning system to help deliver appropriate overall care to people living at the home. Residents benefit from a thorough approach to the management of medication and staff who are aware of the importance of their privacy and dignity. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information from the provider’s visiting reports describe the service staff as working through out the last year to improve the homes care planning system. A number of care plans were inspected during the site visit and found to be in good order. More care is being taken to use social histories and plans are regularly reviewed. All of the plans seen contained appropriate risk assessment and evidence that people cared for are involved in the process wherever possible. From the plans seen it was easy to track how health care needs are being met and the inspector was told that there are good links with local health care professionals. In addition to this the service uses nutritional care plans with appropriate changes to diet and help needed flowing from these. The provider’s visiting reports show service users to be happy with the approach of Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 11 staff and to feel that their privacy and dignity is protected. This picture was consistent with the findings of the site visit. The arrangements for the management of medication were inspected and found to be sound with secure storage and accurate recording. The service manager has notified the Commission of an error in giving out medication earlier this year. This would appear to be an isolated incident of human error and not consistent with the normal standards of practice within the home. The service has moved to a monitored dosage system and staff and the manager told the inspector that this was a more effective and safer delivery system. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 and 15 Quality in this outcome area is adequate . Residents are able to exercise choice and control over their lives. The food served is usually of a good standard with a choice available. The range of activity and stimulation available is an area for future development. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Observation and discussion on the day of the site visit indicated that people enjoy a relaxed atmosphere, where they are able to exercise choice and control in their day to day lives. Comment within the provider’s visiting reports is also supportive of this picture. The staff attempt to provide some activity on each week day and those residents spoken with were broadly happy with the provision. However in the inspector’s opinion this is an area which would benefit from further development and imagination. The home has purchased a large screen television in the last year and plan to have cinema days. They have introduced nutritional monitoring to help ensure that residents’ dietary needs are met and general feedback during the site visit showed people were mostly satisfied with the food served. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is (good). That the providers approach to complaints and adult protection helps in the protection of those who live at the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During the last year the Commission has received one complaint relating to failure to provide adequate staff supervision in the home’s dementia unit. This complaint was passed to the provider and based on records seen during this site visit and information provided by the provider, has been satisfactorily resolved. The complaint record was seen during the site visit and showed that issues raised were being addressed by the service management. The provider continues to train staff in adult protection and staff spoken to told the inspector that they would know how to raise concerns and be confident to do so. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 Quality in this outcome area is ( good). People living at the home benefit from a well maintained, clean and generally comfortable home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The last inspection of the service found a clean and well maintained home offering generally comfortable accommodation to those who live there. With the exception of normal maintenance. The provider’s visiting reports show that this continues to be the situation. A tour of the building undertaken by the inspector during the site visit found the home to be clean and fresh in all areas. During the last year a number of rooms have been decorated and new pictures have been hung in many areas of the home. Within the dementia unit redecoration has taken place and the provider has incorporated colour schemes drawn from expert guidance provided by the University of Stirling. The home has also been successful in obtaining grant money which will allow a major redevelopment of this unit’s garden area. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 15 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 consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 Quality in this outcome area is ( good). Residents needs and wishes are met by the staffing levels and staff are trained to deliver effective care. The employment of staff is carried out in a thorough manner. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Since the last inspection of the service the provider has increased staffing and reorganised the staffing patterns at the home. Provider visiting reports received by the Commission have indicated that the resultant changes have allowed for more effective care delivery and during the site visit staff on duty told the inspector that the increase had been very beneficial. The inspector was told that the workload was still heavy, however given normal staffing effective care could be delivered. The provider continues to offer a good range of training and a new member of staff described her induction as a thorough process. Employment processes are robust and contribute to the protection of people living at the home. During the site visit residents told the inspector that they valued the staff who worked hard for them and this picture is consistent with the providers own visiting reports. Observation during the site visit showed staff to work in a patient and caring manner. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 16 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 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 Quality in this outcome area is ( good). Residents and staff continue to benefit from a well established management structure and a sound approach to running the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: As with the provider’s other services there is a robust management structure in place, both within the home and in the wider organisation. The provider has well established systems and policies in place for involvement in residents’ financial affairs and to ensure appropriate health and safety. During the site visit the inspector looked at sample records relating to health and safety and the management of residents’ finances. In both cases they demonstrated a Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 17 sound approach. The provider has its own quality system based on survey and the annual report for the home was available during the site visit. Information gained from the provider’s visiting reports showed that those who attend the residents committee find it a useful forum for raising issues and residents spoken mostly said they feel they live in a good home operating in their best interests. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 18 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 x x 3 x x 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 x 3 x 3 x x 3 Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 19 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 OP12 Good Practice Recommendations That the management and staff consider ways in which they promote a more varied programme of individual and group activity. Beauchamp House DS0000035242.V344079.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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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