Inspection on 17/04/07 for Beaufort Hall Nursing Home

This inspection was carried out on 17th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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

Beaufort Hall Nursing Home 04/02/09

Beaufort Hall Nursing Home 08/01/09

Beaufort Hall Nursing Home 20/11/07

Beaufort Hall Nursing Home 10/10/06

Beaufort Hall Nursing Home 01/06/06

Beaufort Hall Nursing Home 14/10/05

Beaufort Hall Nursing Home 05/05/05

Beaufort Hall Nursing Home 17/08/04

Beaufort Hall Nursing Home 14/05/04

Similar services:

The Vicarage

Fairfields Country Rest Home

7 Hyde Road

5 Seafield Road

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

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

CARE HOMES FOR OLDER PEOPLE Beaufort Hall Nursing Home 28 & 30 Birnbeck Road Madeira Cove Weston Super Mare North Somerset BS23 2BT Lead Inspector Patricia Hellier Unannounced Inspection 17th April 2007 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 Beaufort Hall Nursing Home DS0000050501.V335698.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. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaufort Hall Nursing Home Address 28 & 30 Birnbeck Road Madeira Cove Weston Super Mare North Somerset BS23 2BT 01934 620857 01934 414426 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) Boyack Enterprises Ltd Mrs Jacqueline Margaret Bowen Care Home 33 Category(ies) of Old age, not falling within any other category registration, with number (33), Physical disability over 65 years of age (6) of places Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. May accommodate up to 6 persons aged 65 years and over with physical disabilities May accommodate up to 33 persons aged 65 years and over requiring nursing care 10th October 2006 Date of last inspection Brief Description of the Service: Beaufort Hall Nursing Home is registered for 33 elderly people aged 65 years or over. The home is on Weston-Super-Mare seafront and occupies a prominent position overlooking Marine Lake. The approach to the main entrance of the home is up a steep slope. Wheelchair access is available at the other end of the building. The home has 25 rooms used as single occupancy and four double rooms. All rooms have en suite toilets. Beaufort Hall is a four-storey building and has a six-person passenger lift accessing all floors. The home has been suitably adapted for the current resident group with handrails in corridors and grab rails in toilet facilities. There is a large dining room on the ground floor and two spacious lounges on the first floor, each of which has a small dining area. The home has a nurse call bell system throughout. There is a Registered Nurse on duty at all times. The home is well maintained and comfortably furnished. It is close to local amenities and the town centre. The current fees are £523.57 per week with additional charges being made for hairdressing, chiropody, newspapers, escorts, toiletries and social therapy entrance fees. This information was provided in April 2007. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This key inspection took place over two days with two inspectors and was made in response to a serious complaint CSCI had received regarding care practices. The manager was present for the first day but not the second. Before the inspection the information about the home was received from a review of the last inspection report and all correspondence and regulatory activity since the last inspection. The accumulated evidence for this report comes from the above and also fieldwork that included the following: discussions with 13 residents, 3 relatives and 10 staff, observation of practices, tour of the premises, review of documents relating to care, recruitment and health and safety; review of policies; inspection of medication records and storage. As part of the inspection the recent complaint regarding care practices were investigated. The complaint is upheld as can be seen throughout the report. All residents and staff spoken with told the inspector that the home was good and the staff kind. Comments received were “it is very homely and comfortable”; “I am quite independent so I can more or less do what I want” “the staff are very kind and I know they are busy so I go along with what they want”, “my relatives care needs are well met”. What the service does well: What has improved since the last inspection? Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 6 The practice of leaving medications for residents to take at a later time has stopped. The nurse administering medications observed them being taken by the resident. The quality assurance process has been improved and regular audits and surveys of residents are undertaken. The electrical wiring of the home has been assessed and passed as safe. 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. Beaufort Hall Nursing Home DS0000050501.V335698.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 Beaufort Hall Nursing Home DS0000050501.V335698.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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 1,2,3,4,5 The Statement of Purpose and Residents’ guide is comprehensive and provides prospective residents with information to make an informed choice. The home’s assessment process is not consistent and information gathered is not always enough to ensure the home is able to meet residents’ needs. Prospective residents and relatives are encouraged to visit the home to assess suitability. EVIDENCE: Residents are provided with a comprehensive Residents’ booklet containing the Statement of Purpose and all the information required to ensure they or their relatives have access to the relevant information at all times. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 9 Copies of Contracts and Terms and Conditions documents were not available in the home for inspection. These documents should be kept in the home and be available for inspection. Pre admission assessments are carried out prior to admission. Those reviewed during the inspection showed an inconsistency in the level of assessment and information gathered. Of the three care plans reviewed one contained all the information to provide an initial plan of care on admission. The other two had very little information. One contained the statement to be assessed throughout, giving staff minimal information to work with. This is not good practice and a full assessment of all care needs must be made prior to admission. One recently admitted resident when spoken to said ‘I am well looked after; they know what I need, and if they don’t I tell them”. Care practices observed showed that staff were aware of the residents needs as stated in their assessments. Prospective residents are invited to visit the home prior to moving in. Beaufort Hall Nursing Home DS0000050501.V335698.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 7,8,9,10,11 Care plans do not always give clear information to enable staff to meet residents’ health and social care needs. Personal and environmental risks are well managed. The system in place for the management of medicines is satisfactory and provides the necessary safeguards for the protection of residents. Dignity and respect are not well maintained by staff, when assisting residents. EVIDENCE: Care plans reviewed reflected the pre admission assessments. One of the seven care plans inspected did not contain any information relating to a hospital admission and the care needs for the resident following this. Two other care plans seen lacked consistency, while four care plans were very concise with life histories and personal preferences noted. Care plans made reference to bathing, but records of care given showed one resident had not had a bath or shower for a month, while another for two weeks. During this time bed baths or body washes have been given. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 11 Nine of the residents are washed and got up and dressed by the night staff. None of these spoken with have had a bath for some time and care plan records show body washes. All residents referred to being washed in the bed or chair. One resident told the inspector they wake me up and get me up and dressed”. This comment was made at 07.00hrs. Two care plans inspected did not show evidence of involvement of the specialist Health Care Professionals to assist the home in meeting the residents’ health care needs. E.g. the Tissue Viability nurse for wound care, the Continence Nurse Specialist for bowel management Treatment being given, as described by care staff, does not follow current guidelines for good practice. All care plans had risk assessments for Manual Handling, Nutrition and where appropriate pressure sore management. The information on these was inconsistent and on one, the actions to minimise the risk did not reflect the level of risk identified. Two risk assessments and care plans identified potential for developing a pressure sore but pressure relief equipment was not in place. One resident for whom pressure relief equipment was not in use was observed in the same position, in the chair in the lounge, throughout the inspection. All care plans had been signed by the resident, or a relative/advocate, demonstrating their involvement in the care planning process. In one care plan the residents’ preference for care delivery had been noted and changed accordingly. Staff spoken to did show an awareness of their role as a ‘key worker’ and the needs of the residents in their care. This was not reflected in staff practices observed in the home throughout the inspection. Over the two days staff were observed on five occasions using a handling belt to assist three residents when moving them. The care plans for these residents clearly indicated the need to use a stand aid. On one occasion two members of staff were observed to say 1, 2, 3 stand but lifted the resident before they got to three. The system for the management of medicines was not fully inspected, but the administration practices were observed and discussed. The medication rounds observed on the two days showed good practice with staff staying with residents until they had taken their tablets. A clear system for the recording of medications entering and leaving the home was seen. All medication was observed to be appropriately stored. Medication Administration Records (MAR) inspected for all residents showed few gaps and codes relating to the missed dosages used. Several medication sheets showed that medication to be administered three times a day is not well spaced out and is being given at four hourly intervals instead of six to eight hourly intervals. Several other medication charts showed night sedation being administered at times ranging from 17.00 to 22.00hrs. It is recommended that the GP be asked to review Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 12 prescribed medications to ensure they meet the needs of residents. Staff in the home should review the times medications are administered, to ensure they meet the needs of the residents, and are evenly spaced out throughout the day. Over the two days staff interactions with residents did not reflect an awareness of the need to treat residents with respect and dignity. Two members of staff were observed feeding residents at lunchtime. They were talking to each other across the residents during the mealtime; staff did not talk to residents other than to say it was lunchtime. Five residents were sat in the pink lounge on the first day of the inspection. When one resident made several attempts to talk to staff they all ignored the resident and walked away just saying hello or yes over their shoulder. This behaviour was observed at all levels of the staff team. During the second day of the inspection an inspector was talking to a resident; a care worker walked in, sniffed the air, walked over to the resident and said to the inspector; Oh s/he has got diarrhoea, yes s/hes got diarrhoea again. Then walked away. The inspector then waited, and noted that it was another 20 minutes before the resident was taken to the bathroom. All residents spoken with said, “the staff are good they do what they can”; “I am well looked after”, “I can do what I want when I want”, they are always there when I need them”. The home has an Equality and Diversity policy that recognises the cultural and social needs and differences that are present in society. This policy was not seen being implemented in the care provision to residents; e.g. those who have a degree of mental incapacity were not spoken to and involved, as able, in the actions to be taken to assist them. Choices and preferences were not offered. In discussion management and staff demonstrated clear knowledge and desire to meet cultural and diversity needs as and when they should arise. Residents’ wishes in death were not well recorded in all care plans inspected. Two of the care plans of residents that have been residing in the home for sometime said, “to be discussed later”. Residents’ wishes regarding their care at the end of life should be discussed and recorded to enable good person centred care to be given. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 13 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 12,13,14,15 Social activities are limited and routines inflexible. Friendly staff always welcomes relatives and visitors EVIDENCE: Of the six care records reviewed it was evident that some residents did attend the occasional reminiscence session. The care plans however indicated that they generally watched TV or listen to the radio. Over the course of the two days the residents in the pink lounge were seen to be sat with the television on and in the ‘blue lounge with the radio on’. They received no other stimulation. Staff did not engage them in conversation or provide books or magazines to look at. One resident said, “ I am bored, I just sit here all day and sleep mostly”. The five residents were observed either dozing in their chairs or looking around the room. Few visitors were seen entering or leaving the home on either day of the inspection. The only interaction with staff was toilet rounds or mealtimes. Some comments from residents in the home’s quality assurance questionnaire indicated a lack of activities that they personally would like to attend. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 14 Although care plans do mention personal preferences, over the two days there was little evidence of the less able residents having choice or control over their lives. Residents are allocated to either the blue or pink lounge; they dont have the choice. Residents with a degree of mental and physical ability did say they have a choice and could go out if they wished. Care plans did indicate residents with preference to early rising’. The night nurse stated that they have nine residents to wash and dress every morning, and to achieve this they must start at 06.15hrs. The night nurse stated that it was the same nine residents every morning. During the second day staff were observed waking residents up so they could be washed and dressed in time. By 07:30hrs. all nine residents were up washed and dressed. Some were then observed to be sleeping in their chairs. Two residents up washed and dressed stated that staff had woken them up. One resident told the inspector she had been allowed a lie in, despite being dressed and in the lounge by 08.00hrs. All the residents spoken with said that the ‘food is good’ and choice is available if wanted’. The dining room is homely and tables well presented. For residents that need assistance with their food a pleasant area in one of the lounges is used. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 16,18 Residents are confident that they are listened to and their requests acted upon. Residents are potentially at risk from staff who do not recognise their poor practice and allegations/ complaint are not well managed. EVIDENCE: The home has a complaints procedure which all residents have a copy of. It is not publicly displayed but residents and relative spoken with said they knew whom to complaint to and they would “speak to the manager”. A record is maintained of complaints brought to the manager of the home. The latest complaint brought to the manager through the Commission for Social Care Inspection was not recorded. Records showed two complaints since the last inspection. The complaint referred to above was about poor care practices in the home in relation to privacy and dignity and manual handling practices. An allegation of abusive behaviour from a member of staff to residents was also received. This is currently being investigated separately. The management of the home have attempted to find out who made the allegation, and has thus not adhered to their own whistle blowing policy. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 16 The home has a copy of the ‘No Secrets’ in North Somerset guide and a comprehensive local policy and procedure for responding to allegations of abuse for the protection of residents. Staff when interviewed demonstrated good knowledge of what abuse is and how it should be dealt with. Staffs’ knowledge and actions were incompatible with their lack of recognition of the potential for abuse, and with some of the practices observed in the inspection. Staff have recently attended a training event in Safeguarding Adults. Six residents said ‘the staff are kind and I have no complaints, I am very happy here”. Consent for use of bed rails and recliner chairs had been obtained from residents or their relatives to protect residents from potential restraint against their wishes. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 19,20,22,24,25,26 Residents are provided with homely, safe and comfortable surroundings. The home has suitable equipment to maximise resident independence. Robust Infection control practices are followed EVIDENCE: A tour of the premises was carried out. It was evident that there was a programme of redecoration and refurbishment, with empty rooms being decorated. All areas are accessible and adequate communal space is provided. All bedrooms were well furnished and showed signs of personal belongings. One resident stated she had ‘bought in her own furniture to make it feel more like home’. Despite work undertaken last year, and reference to some fire doors not closing properly in the last two inspections, it was noted that several bedroom Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 18 doors did not shut properly. They either caught on carpet or door jams. These are fire doors and it is essential for the safety of residents in the event of fire that these doors create a secure seal against smoke. It was noted that some areas fell short of providing a safe environment. Three bedrooms did not have window restrictors; all three had an item of furniture next to the window. This does not protect residents from falls from heights. During both days the home was clean and tidy and free from offensive odours. The home has grab rails situated at relevant points and a shaft lift that is easily used to assist resident mobility and aid independence within the home. All resident rooms are provided with locks that are accessible to staff in an emergency. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. 27,28,29,30 The home’s staffing levels are sufficient to manage the care needs of residents. Recruitment procedures in place do not provide all necessary safeguards for the protection of residents. Staff do not receive adequate training to enable them to provide safe and knowledgeable care to residents. EVIDENCE: Copies of two weeks staffing rosters were inspected. Staffing levels planned were sufficient to meet residents’ needs. All of the residents spoken with told the inspector “staff are always there when you need them”, “ you ring the bell and they come”. A sufficient team of ancillary workers supports care and nursing staff to ensure the smooth running of the service. The staff team are not resident focussed but task orientated with allocations of tasks to each carer for each shift. E.g. one member of staff had been assigned toileting and bells. Staff reported that a lack of teamwork at times can affect working practices. They spoke of times when there are difficulties in the team and standards of care delivered slip. Staff observed during the two days of inspection had minimal interactions with residents and their approach did not show respect or a person centred Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 20 approach to each resident. See comments in section two – Health and Personal Care. Residents spoken with said, “the staff are always busy but they come when they can”, another said, “I try and avoid a couple of them as they can make me feel a nuisance”; “I am happy enough”; “I am old so I can’t really ask for anything”. Five staff files were inspected. Two contained only one written reference, one did not have any proof of identity and none had evidence of previous qualifications. In three files there were gaps in employment or significant events in their past employment history for which there was no evidence to suggest that these issues had been discussed with the individual prior to employment for the safeguarding of the residents. A number of staff from overseas are employed at the home and form part of the close-knit team. Staff and residents said their presence brought a breadth of experience and interest to the home. Three residents and two members of staff told the inspector that these staff could be overheard speaking in their own languages together in front of the residents. Overseas staff interviewed said they ‘felt very welcomed in the home, enjoyed their jobs and were improving their English’. Staff spoken to stated that they received plenty of opportunities to attend training. On the second day some staff attended a training session on Bowel management. Although staff spoken to said that they had received training in Manual Handling, Fire and First Aid, training records did not reflect this. With a total of 36 members of staff, 12 had up to date Manual Handling training, 13 up-to-date Fire training and only 8 with a First Aid certificate. It is a requirement that all staff attend annual updates in Manual Handling and Fire procedures. It is also a requirement that there is a qualified First Aider on each shift including the night shift. Records of staff induction seen were sparse and staff interviewed could not recall much of their induction. One person said they had shadowed another carer for a few shifts. It is recommended that attention be paid to the induction of new staff to ensure the provision of best practice care and that staff are fully equipped with the necessary skills to meet residents needs. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 21 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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. 31,32,33,34,36,37,38 The underpinning management practices do not provide clear leadership and direction to staff. Residents’ views are sought and acted on, but a formalised system is not in place. The management of resident’s monies are handled safely by the home Health and safety issues are not regularly monitored in the home and a safe environment not always maintained. EVIDENCE: The manager has a wealth of experience in care of the elderly. Residents feel the manager is approachable, available and seeks to ensure all their needs are met. Staff interviewed felt the manager is approachable but does not always Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 22 respect confidentiality. Through recent regulatory activity and the inspection it was apparent that the manager is not following the home’s policies and procedures in the way in which situations within the home are being managed. List of tasks are produced and staff are required to complete tasks in a set time. This does not provide for a person centred approach to the running of the home. This together with gaps in documentation demonstrated a weakness in the underlying management structures of the home, and potentially puts residents at risk. The registered provider is not actively involved in the management of the home and supports any actions the manager takes. The home carries out a quality assurance procedure, forwarding questionnaires to residents. The questionnaire covers four areas, environment, food, activities and staff. A numerical score is taken for each area. These are then collated to give an overall numerical outcome. The quality assurance report does not show what the organisation intends to do when comments are made by residents. Some residents had stated activities were poor but there was no written indication to say how the organisation was going to improve activities, or consult with the residents about the activities they wanted. During the course of the inspection the home had 17 residents, a level of 50 occupancy. In discussion with the manager it seems that the home has been running at this level for sometime now. The provider has been asked to submit to the Commission documentation regarding the financial viability of the home. Staff spoken to said they “received an annual appraisal and clinical supervision when they were shown how to carry out procedures in the home”. They stated that they did not receive regular formal supervision where they could discuss their needs and aspirations. A formalised system of supervision needs to be implemented to monitor practice. During the course of the inspection it became apparent that deaths, illness and significant events had not all been reported to CSCI as required. All the documentation for health and safety checks and service records were available and but they were not all up to date. The fire log indicated as previously mentioned under NMS30 (training) only a third of the staff complement had attended a formal fire training session, provided by an accredited trainer. The fire records also showed that many of the staff compliment had not taken part in a fire drill since December 06. This drill did not include night staff. Firefighting equipment was regularly serviced as was indicated in the service record, however there was no record of visual checks being carried out by senior staff in between the service dates. Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 23 As mentioned in the environment section a number of bedroom doors did not shut properly. They either caught on carpet or door jams. These are fire doors and it is essential for the safety of residents in the event of fire that these doors create a secure seal against smoke. Risk assessments for working practices within the home had been completed, these were dated October 05 with a planned Review date for October 06. They did not appear to have been reviewed at the time of the inspection. Beaufort Hall Nursing Home DS0000050501.V335698.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 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 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 1 9 3 10 1 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 X 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 1 2 3 X 2 X 3 3 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 2 1 1 X 1 1 1 Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 25 YES 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. 2 3 Standard OP3 OP7 Regulation 14.1 (a) 15.1 13.1 (b) Requirement A full assessment of needs must be carried out prior to admission Care plans must be consistent in the guidance provided for staff to enable good care for residents. The registered person to ensure that other specialist Health Care Professionals are consulted to assist in the meeting of health care needs. The registered person must ensure that the home is conducted in a manner that respects the privacy and dignity of people who use the service. All residents must receive a programme of meaningful activities to meet their social needs. The registered person must ensure that all staff have a clear understanding of what abusive practice is, and to help ensure that residents are safeguarded from harm. Recruitment practices must ensure that all the necessary documentation has been obtained prior to commencement DS0000050501.V335698.R01.S.doc Timescale for action 30/05/07 30/05/07 10/06/07 OP8 4 OP10 12.4 (a) 30/05/07 5 OP12 16.2 (m) 30/05/07 6 OP18 13.6 30/05/07 7 OP29 19.1 Schedule 2 30/05/07 Beaufort Hall Nursing Home Version 5.2 Page 26 8 OP33 24 of employment at the home and issues of significance discussed and noted. The quality assurance report must indicate how the organisation is going to tackle issues raised by residents. Previous timescale of 28/08/06 and 31/01/07 not met The registered provider to submit to the Commission information and documents showing the financial position of the care home All staff must receive formal supervision that is clearly documented The registered person must ensure that all fire doors close fully and are not left wedged open at night. Previous timescale of 20/11/07 not met All staff must attend accredited fire training and take part in a fire drill. Visual checks of fire fighting equipment must be carried out All staff must attend accredited Manual Handling training 30/07/07 9 OP34 25.2 30/05/07 10 11 OP36 OP38 18.2 23.4 (c) (i) 30/06/07 30/05/07 12 OP38 23.4(d) 30/05/07 13 OP38 13.5 30/06/07 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 OP2 Good Practice Recommendations A copy of the Contract, or Terms and Conditions, of residency for each resident should be kept in the home at all times. DS0000050501.V335698.R01.S.doc Version 5.2 Page 27 Beaufort Hall Nursing Home 2 3 OP3 OP11 Assessments contain full information regarding social care needs and preferences to inform the care plan. Residents wishes regarding death to be recorded to ensure all staff have the knowledge to provide sensitive care at this point. Carried forward from last inspection The home should enable all residents to exercise choice and control over their lives. All complaints should be record when received and action taken in accordance with the homes policy. All windows should have restrictors attached, or wellformulated risk assessments in place to ensure the safety of residents from potential harm. All staff should be provided with a full induction in line with the Common Induction Standards. All staff should attend annual mandatory training All environment risk assessments should be reviewed and updated 4 5 6 OP14 OP16 OP19 7 8 9 OP30 OP30 OP38 Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Taunton Local Office Ground Floor Riverside Chambers Castle Street Taunton TA1 4AL 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. Extracts may not be used or reproduced without the express permission of CSCI Beaufort Hall Nursing Home DS0000050501.V335698.R01.S.doc Version 5.2 Page 29 - 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. 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