CARE HOMES FOR OLDER PEOPLE
Beaumanor Nursing and Residential Home Cartwright Street Loughborough Leicestershire LE11 1JW Lead Inspector
Debbie Williams Unannounced 17 June 2005 10:00 am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Beaumanor Nursing and Residential Home Address Cartwright Street Loughborough Leicestershire LE11 1JW 01509 239443 01509 239443 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Rushcliffe Care Limited Mrs Lyn Peach Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (53), Physical disability (28), Physical disability of places over 65 years of age (53), Sensory impairment (2), Sensory Impairment over 65 years of age (2), Terminally ill (2), Terminally ill over 65 years of age (2) Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: none Date of last inspection 7th of january 2005 Brief Description of the Service: Beaumanor is a care home situated on the outskirts of Loughborough and is registered for fifty-three nursing and residential beds, providing personal and nursing care for older persons. The home is located close to the centre of the town within a fifteen-minute walk. and is situated within a ten-minute walk of the train station. East Midlands Airport is a thirty-minute drive from the home.The home is purpose built and accommodation is on two floors accessed by a passenger lift. all bedrooms are single with en-suite facilities, all areas of the home are accessible to service users in wheelchairs. Situated on the banks of the famous Grand Union Canal the home has pleasant views of Narrow boats and Canal events are a regular feature. The home has a patio area with a pond and greenhouse. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place over four hours and was facilitated by the home’s registered manager. The inspector selected four service users and tracked the care they receive through review of their records, discussion with them (where possible), the care staff and observation of care practices. Staff members were spoken with regarding training and support. This was a positive inspection and was facilitated by the manager and staff in a helpful, friendly and professional manner. What the service does well: What has improved since the last inspection? Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 6 Care planning and record keeping has improved since the last inspection. Records inspected appeared to meet all assessed needs and set out in detail the care required and the care provided to each individual resident. Care plans also included a list of medication prescribed to each resident, any potential side effects which may occur and when this medication was last reviewed by a GP, the home was commended for this practice. 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. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4. Prospective residents are provided with clear and comprehensive information that enables them to make an informed decision before moving into the home. Assessment procedures are robust so ensuring that all needs are identified and can be met. EVIDENCE: The homes Statement of Purpose/service user guide is clear and comprehensive, a copy is provided to all prospective service users and can also be found in each residents private accommodation. A copy of the home’s terms and conditions and an invoicing agreement was seen in the care records of the four case tracked residents. Assessment records for four case tracked residents were inspected. Assessment records were comprehensive and included appropriate risk assessments. The home provides nursing care and is staffed with qualified nurses at all times. One of the case tracked residents was from an ethnic minority
Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 9 community, the service appeared to be meeting their cultural and religious needs, this was confirmed by the resident. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 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 standard(s) 7, 8, 9 and 10. Comprehensive care policies and procedures support staff to meet residents needs in a safe, respectful and appropriate manner. EVIDENCE: Care plans for four case tracked residents were inspected. Care plans were comprehensive and appeared to meet all assessed needs. Appropriate risk assessments were carried out, these included, nutritional, falls, pressure sore and general risk assessments. Contact with other healthcare professionals such as GP’s and community nurses was detailed within individual care records. Medication administration records were inspected for two of the case tracked residents, these appeared accurate and in good order. Medication storage areas appeared in good order and to comply with regulations. Controlled medication stocks were checked for one resident, records appeared accurate. Each service user has a care plan specifically for medication. This lists the medication each resident is prescribed and any potential side effects. This is
Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 11 commended as good practice. A record of each time medication is reviewed is also maintained. Medication is administered by qualified nurses, a reassessment of their competencies is undertaken annually, this is also commended as good practice. The inspector observed interaction between staff and residents, interactions appeared positive and respectful. Two of the residents spoken with felt that staff treated them with respect and maintained their privacy and dignity. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 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 standard(s) 12 and 13. Activities of daily living are made flexible to suit resident’s needs. Residents are able to satisfy their social, cultural and religious needs. EVIDENCE: Residents spoken with confirmed they were able to choose how to spend their day and that their visitors were made welcome at all times. An activities organiser is employed at the home and activities on offer included bingo, cards, music and movement and trips out. Social, religious and cultural needs are recorded in individual care records. One of the case tracked residents was from an ethnic minority community, the service appeared to be meeting their cultural and religious needs, this was confirmed by the resident. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 13 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18. Complaints and adult protection policies were robust and afforded protection and minimised risk to all service users accommodated. EVIDENCE: The home’s complaints and adult protection policies were robust. One staff member spoken with confirmed they had received adult protection training. A record of all complaints received is maintained. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 14 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 26 The service provides a well-maintained environment that appeared safe and comfortable. EVIDENCE: All areas of the home inspected appeared clean, hygienic, well maintained and comfortable. A maintenance person is employed at the home and carries out routine maintenance checks as well as attending to repairs as required. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 30. Staff numbers were not always sufficient to meet the needs of the residents accommodated at the time of this inspection. Staff training was comprehensive so ensuring that staff were trained and competent to do their jobs. EVIDENCE: At the time of this inspection there were 47 residents living in the home (three were in hospital). A copy of the home’s duty roster for the week in which this inspection took place was inspected. Care hours for this week were 820. According to the Department of Health’s staffing guidance and based on the dependency levels of the residents accommodated, there was a shortfall of seventy care hours for this week. Staff and residents spoken with felt that the service would benefit from an increase in care staffing hours. Staff training records were inspected and found to be comprehensive, this included induction and foundation training. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 and 38. Financial procedures protected the financial interests of residents. Health and safety policies and procedures were comprehensive and promoted protection for residents. EVIDENCE: A facility to store small amounts of resident’s personal money is provided. Transaction records were seen and these appeared accurate and in good order. The home has comprehensive health and safety and risk assessment policies. The company maintenance man is responsible for the checking of hot water temperatures. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 17 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 N/A N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 4 10 3 11 N/A DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 N/A 15 N/A
COMPLAINTS AND PROTECTION 3 N/A N/A N/A N/A N/A N/A 3 STAFFING Standard No Score 27 2 28 N/A 29 N/A 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 N/A 3 N/A N/A N/A N/A 3 N/A N/A 3 Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 18 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 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 27 Good Practice Recommendations Staffing levels should be calculated using the Department of Healths staffing guidance and should meet the needs of service users accomodated. Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 19 Commission for Social Care Inspection 5 Smith Way Grove Park Enderby Leicestershire LE19 1SX 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 Beaumanor Nursing and Residential Home C51 S1888 Beaumanor NR V232784 170605.doc Version 1.30 Page 20 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
