Inspection on 29/06/06 for Beauchamp House

This inspection was carried out on 29th June 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beauchamp House 21/06/07

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 Key Unannounced 29th June 2006 09:30 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.V305259.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.V305259.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 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) Norfolk County Council 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.V305259.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. 13th September 2005 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. Beauchamp House DS0000035242.V305259.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 servcie. 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 or visit the home. This has included a recent unannounced visit to the home and this report gives a brief overview of the service and the current judgements for each outcome group. What the service does well: What has improved since the last inspection? The service has continued to recruit staff and as such are using many fewer agency staff. Good levels of staff supervision have been established and maintained. Staff training has been extended. Care plans have improved with more consistent recording and clearer guidance. Beauchamp House DS0000035242.V305259.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. Beauchamp House DS0000035242.V305259.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.V305259.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3,6 Quality in this outcome area is poor, however had the service been able to demonstrate that it was remaining within its registration conditions at all times then the outcome would have been adequate. This judgement has been made using a range of information including the site visit to the service. Prospective service users do have the necessary information to allow them to make an informed choice of home, however the service must take care to ensure that all admissions are within the homes registration conditions and that all assessed needs can be met, particularly in relation to staffing levels. The home has a good quality intermediate care service enabling positive outcomes for many people striving to continue to live independently. EVIDENCE: The management confirmed that the service has had no permanent admissions since the last inspection of the service and discussion with the service management indicated that they were aware of their need to ensure that they could meet need adequately. Examples were given of recent referrals which had not been proceeded with. However examination of sample case records did involve looking at the admission process for a service user who has been Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 Page 9 accommodated on several occasions for periods of respite care. Whilst the initial assessment gave a broadly adequate assessment of care need, each subsequent stay had much more limited information and there was no evidence of the service carrying out its own assessment of need before each visit in order to assure itself that the placement was appropriate. It was also noted by the inspector that the assessment seen clearly stated that the service user has Alzheimer’s Disease and yet was being accommodated in the main home which does not have a Dementia registration. The services homeward bound unit was empty at the time of inspection, however the inspector spoke to the occupational therapist from the unit, looked at the record of comments from previous service users and looked at a care plan. The unit offers a structured approach to service users who need help to gain the skills needed to continue living independently and based on the analysis of outcomes produced by the service has a high success rate. The services regulation 26 reports indicate that service users receive all necessary information to allow them to make an informed choice when entering the home and a service user guide is available in the entrance area of the home. Beauchamp House DS0000035242.V305259.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made based on evidence from the site visit and other information available to the commission. Service users benefit from a clear plan of care and they are involved in the process. Medication is appropriately managed and service users receive care which recognises their right to privacy and dignity. EVIDENCE: The last inspection of the home (September 05) indicated an improved and generally satisfactory approach to care planning. The providers subsequent regulation 26 reports have confirmed this picture with confirmation of staff involving service users and or their relatives in the process. Sample plans seen at this site visit were in good order with evidence of service user participation, regular review and necessary risk assessments in place. Care plans also allowed for the tracking of how health care needs were being met and from this it would appear that all health care needs are being satisfactorily addressed. Comments received from service users both on the day and in surveys, indicated that people felt well cared for. Observation of interaction between staff and residents showed care to be delivered in a warm and kindly Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 Page 11 way. Service users told the inspector that their dignity and privacy was respected by staff. The management of service users medication was inspected. All medication was satisfactorily and securely stored and sample recording was in order. Part of a lunch time medication round was seen and the practice was appropriate. Regulation 26 reports have identified a shortage of moving handling aides in relation to the size of the building and the dependency levels of service users. This was confirmed to the inspector by staff spoken to and the service management. Such a deficit would normally result in a requirement, however the inspector is satisfied that action has already been taken to rectify this, none the less the service management must keep this area under regular review to ensure that staff have sufficient equipment to care safely at all times. Beauchamp House DS0000035242.V305259.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate. This judgement has been made based on evidence from the site visit and other information available to the commission. EVIDENCE: The service has a structured programme of activity which includes trips out from the home. At the site visit the inspector saw photographic displays of service users enjoying these and other activities. Service users spoken to confirmed that they were happy with the level of activity and stimulation and comment cards received expressed no dissatisfaction with this area of care . The last inspection of the service (September 05) indicated that the service should work towards enabling a better balance between group activity and the opportunity , however given that there has been no increase in staffing it is likely that time spent one to one is still a rarity. Survey results, discussion at the site visit and information from regulation 26 reports show a good degree of satisfaction with the food served, which was said to be tasty and plenty of it. Management confirmed they had acted in response to a recommendation made concerning pureed food. All service users spoken to felt at home and free to choose their life style and the inspector was told that their visitors are made welcome. Beauchamp House DS0000035242.V305259.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are able to express concerns safely and with confidence that they will be listened to. The providers approach to adult protection is robust and provides an appropriate framework for the protection of service users. EVIDENCE: The home has a written complaints procedure which is consistent with legislation and standards. This procedure is displayed and has also been given to all service users and their families. The commission was aware of one complaint from earlier this year and based on discussion with the service management this has been resolved through meetings and discussion with the service users family. Examination of the services complaints record showed an appropriate approach to complaints and there was no indication from commission surveys of issues in this area. Staff working at the home have received adult protection training and the local authority has well developed procedures in this area. Beauchamp House DS0000035242.V305259.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users benefit from a clean pleasant and homely atmosphere EVIDENCE: This visit found the home to be clean and fresh and this is consistent with the findings of other visits to the service in the last year. Service users spoken to confirmed this as did the survey responses. The building is generally well maintained with bedrooms and communal space being suitably furnished and equipped. Service users spoken to were happy with their rooms and those rooms seen had been personalised. The home is dived into units with each unit having its own pleasant garden area. It was noted that in some of the ground floor areas there is no natural light in the central communal space which is less than desirable. Although this is a design fault and as such cannot be rectified, the inspector recommends that every effort is made to compensate through good quality artificial lighting in the interests of service users safety, comfort and mental wellbeing. Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 Page 15 The providers recent regulation 26 reports have identified a number of areas for repair and redecoration. Discussion with the service manager at the site visit indicated that all areas had been actioned or the work involved had been commissioned. The service has one unit on the ground floor which operates as a dementia unit. The unit is secure with a secure garden area. Recent regulation 26 reports have identified this area as being poor in appearance and it was confirmed by the manager that a programme of redecoration is planned. As such the inspector strongly recommends that good practice guidelines relating to design for dementia are incorporated into the scheme. Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to the service. The outcome would be good if the provider improves staffing levels as the quality of care provided is good and staff are well trained. EVIDENCE: At the last inspection of the service (13/09/05) a requirement was made to review staffing levels to ensure that there was sufficient staffing to meet needs. At this visit to the service it was confirmed to the inspector that a review had been undertaken however the results were not yet known and as such there has been no overall improvement in staffing levels. The service is using less agency staff and has successfully recruited a pool of relief staff which represents an improvement, but their remains concern over overall staffing levels. Feedback from relative surveys, indicated continued concern about numbers of staff on duty from 50 of those returned and although this number was not high it was noted that these concerns were also present in service user surveys, feedback given to the provider in regulation 26 visits by staff and in discussion during the inspection. The inspector spent time during the site visit talking to service users and staff and observing interaction between them. From the above it was clear that staff are hard working, care about there job and are felt to offer an excellent service. However staff continue to feel that dependency levels are high and that they have limited time to spend with residents. Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 Page 17 The last inspection commended the service provider and management for the positive approach to staff training and from information provided prior to the inspection it would appear that there continues to be a satisfactory commitment in this area. Sample employment records were inspected and these demonstrated a robust recruitment process offering protection to service users. Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users and staff benefit from a clear management structure and a generally sound approach to the running of the home. EVIDENCE: Service users spoken to by the inspector were aware of the management arrangements in the home and said they would find it easy to talk to the manager or care coordinators about any issues that they might have. The service manager has nearly completed The Registered Managers Award and although this is his first managers position, he has a good level of experience in the sector. The providers regulation 26 reports show their to be a residents committee which is a useful forum for raising issues. Discussion with service users would indicate that they feel well cared for and that the home operates in their interests. The service does have a Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 Page 19 survey process, however it was noted at the site visit that it is a year since the last survey and the management need to instigate a new process if they are to have an effective approach to quality. The Commissions comment cards highlighted most service users are broadly happy with the service received although there was an anonymous comment relating to a service user having disturbed nights through noise from other service users and one service user spoken to at the visit felt this was a problem. As such the new survey should seek to establish the extent of this problem and thought be given to minimising its effect. The service has established and robust methods for managing service users finances and appropriate and clear records are maintained in support of this. Over the last year much effort has been put into maintaining a formal process of staff supervision and this is being maintained. With the exception of the night shift the service always has a management presence providing day to day support and supervision. There is an appropriate approach to health and safety with procedures policies and training in this area. Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 Page 20 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 3 x 3 x x 4 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 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 2 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 3 x 3 Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? yes 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 OP27 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 health and welfare needs of the residents. Repeat Requirement Timescale for action 31/08/06 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 2 Refer to Standard OP19 OP19 Good Practice Recommendations That the Provider explore ways to improve the artificial lighting levels in the communal space which does not have natural light. That the planned redecoration of the services Dementia unit incorporates good practice guidance for this client group. Beauchamp House DS0000035242.V305259.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Norfolk Area Office 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 DS0000035242.V305259.R01.S.doc Version 5.2 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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