Inspection on 15/08/05 for Beauvale Care Home

This inspection was carried out on 15th August 2005.

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

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

Other inspections for this house

Beauvale Care Home 04/11/08

Beauvale Care Home 03/10/06

Beauvale Care Home 15/02/06

Beauvale Care Home 10/03/05

Beauvale Care Home 13/10/04

Beauvale Care Home 16/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Beauvale Care Home Moor Lane Bingham Nottingham NG13 8AS Lead Inspector Chrisandra Harris Unannounced Inspection 15th August 2005 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 Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 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. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Beauvale Care Home Address Moor Lane Bingham Nottingham NG13 8AS 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) 01949 831263 01949 831355 beauvale@highfield-care.com Southern Cross Care Homes No 2 Limited Susan Margaret Harker Care Home 35 Category(ies) of Old age, not falling within any other category registration, with number (35), Physical disability (3), Terminally ill (3) of places Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Within the total number of beds, a maximum of 3 beds maybe used for the category PD. Within the total number of beds, a maximum of 3 beds maybe used for the category TI. Care Home with nursing for 35 Older People Date of last inspection 10th March 2005 Brief Description of the Service: Registered for 35 people, Beauvale Care Centre provides both nursing and personal care for older people. The home can provide care for three people with physical disabilities and also three who are terminally ill. Refurbishment and redecoration continue through the new company Southern Cross. There is a mix of bedrooms on the ground and first floors with a passenger lift up to the first floor. There are 33 single bedrooms and 1 double bedroom which is en-suite. Outdoor space is limited but pleasant with a grassed back courtyard off the conservatory with seating, the front aspect has a canopy area where service users can sit, there is a large apple tree in the front garden and a small carpark. The home is very close to the centre of the village of Bingham, making the local facilities such as shops, library, the market, and public houses easily accessible. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Inspection commenced at 9.30a.m. and was carried out by two Inspectors, Chrisandra Harris and Lee West. The method used was case tracking, that is the inspectors talk with service users about their expectation and experiences of living at the home, analyses the records of the service users and talks with staff to ensure that those living at the home have their needs met and health and welfare maintained appropriately. 4 service users, three members of staff and two relatives were spoken with. The Administrator and Deputy were on duty and assisted with the inspection process. There were service users in all areas of the home, some visiting the locality, others in the outside areas. The Activities organiser was actively involved with the service users. Some service users were still breakfasting. All this created a busy, lively atmosphere which was observed throughout the inspection. What the service does well: What has improved since the last inspection? 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. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 6 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 Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 7 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): This standard was not assessed at this inspection EVIDENCE: Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 8 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): 7,8,9,10 Care plans are comprehensive and set out clearly the individual needs of service users and the action needed to meet these needs. However some areas are not dated so it was difficult to be clear if they were still current. Service users are treated with respect and their privacy was observed to be upheld. Medication was dealt with properly with none responsible for their own medication. EVIDENCE: Three service user plans were looked at. All contained clear and comprehensive details including risk assessments and details of the action that staff should take to meet individuals needs. However some elements of plans were undated. There was evidence that plans were reviewed regularly and plans were signed by the service user or their representative. Medication records were checked and correctly completed. The policies and procedures in place and being adhered to. Only the appropriately trained staff give out the medication. The home has organised its medication removal system in line with new regulations. Service users spoken with are very happy with the level of dignity and privacy they are given in the home. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 9 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): 12, 13, 14,15 The home provides an excellent range of events and activities, some of these are group events whilst others are a response to individual requests. Relatives and friends are made welcome at the home and can visit at any time. Service users were around and about the home, some were outside and others around the different communal areas. Choice was evident with this activity. Individual choice of breakfast time was evident too as some service users were still breakfasting at the beginning of the inspection. The service users still breakfasting were happy with the food. Service users are given access to their records and can handle their own finances for as long as possible. EVIDENCE: The home employs an activities organiser who arranges a wide variety of trips, events and activities and also provides one to one contact, for example taking individuals to local shops or chatting to them. An attractive display regarding forthcoming events was displayed at the home. Service users spoken with were looking forward to a planned trip to the zoo. Another service user said that she was always consulted about activities but preferred not to join in and Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 10 this was respected. Service users also said that religious events were arranged and they were given the opportunity to be involved if they wished. Service user and relatives signatures were found on the records case tracked and the financial records clearly show the service user involvement. Finances are kept individually and are recorded by the Administrator. All service users have personal possessions within their rooms. Groups of service users were congregated in the communal areas inside and outside of the home and were cheerful and interacting generally. The service users outside said they were enjoying the sunshine and a service user went into the village. Visitors to the home said that they could call at any time and were always made welcome and given a drink. Service users spoken with said that sometimes they saw their visitors in their room sometimes in communal areas depending on their wishes. Individuals are helped to participate in local activities by for example by being given assistance to visit local shops. Service users said that they were given many opportunities for choice and they were able to personalise their rooms and bring furniture if they wished. Service users said that they were happy with the food, although this was not assessed during this inspection. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 11 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): 16 ,18 Complaints are dealt with thoroughly and timely. Staff are aware of Protection of Vulnerable Adults and the correct procedures to protect service users. EVIDENCE: Staff and service users all confirm that they feel any complaints they have will be dealt with quickly and efficiently. Complaints procedure seen. Complaints book shows recent complaints which have been documented, followed up and formal replies written. Service users feel that they are protected and confirm that they can turn to all members of staff if need to. Staff have knowledge of the abuse policies and procedures and records confirm this. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 12 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): 19,20,21,22,23,24,25, 26 The home is comfortable, clean and safe with adequate ventilation and lighting There is a risk of infection as a result of dirty linen passing by the open kitchen door. All the maintenance checks are up to date and carried out regularly. Rooms were clean, personalised to suit service user needs and had their own possessions around them. Specialist equipment was being used to maximise Independence and service users had their possessions around them. EVIDENCE: Four service users bedrooms were seen, two sitting areas and the dining room. All had good natural light with window restrictors fitted to windows, appropriate electric lighting, good ventilation and guarded radiators. The entrance hall has been fitted with additional lighting via standard lamps in response to a requirement made at the last inspection. The laundry room, kitchen and one sluice were seen. The rota for cleaning all areas of the kitchen was seen and was up to date. The laundry room is small and adjacent to the kitchen. Environmental Health have visited in response to Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 13 a requirement made at the last inspection for further advice regarding this, however the deputy manager was not clear as to what their advice was. Laundry procedures observed today appeared to be appropriate, but there remains a risk from dirty laundry in close proximity to the kitchen. The sluice seen was clean and kept locked. All the maintenance checks were carried out and the record books signed appropriately. Service users were actively around the building, some with specialist wheelchairs, scooters and walking frames. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 14 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): 27,28,29,30 The staffing levels are sufficient for the needs of the service users with adequate nurse trained and care staff cover. The deputy’s hours are in excess of E.U. Regulations with her working days and nights which could lead to excessive tiredness and leave the service users at risk. The staff recruited hve al been recruited appropriately with the appropriate checks carried out. Mandatory training is being carried out and implementation of an Induction programme is beginning in the near future. EVIDENCE: Duty rotas for the month seen. The Deputy is working between 60 & 84 hours a week with only one day in between, contrary to E.U.Regulations, Staff files seen contain photographs, evidence of Criminal Records Bureau and Protection of Vulnerable Adults checks. Training Records show evidence of training which has taken place. A blank Induction programme was seen but this is not working at present. Three members of staff were spoken with. All were able to give details of mandatory training courses that they had attended within the past 12 months. One person seen had recently been supported to complete her NVQ Level 2. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 15 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): 33,34,35,37 Service users feel they can speak out if their interests were not being served. The home’s accounting procedures safeguard the service users’ financial interests. The home’s policies and procedures are well documented and new procedures are being put in place following the recent change of ownership. The record keeping seen was up to date, clear and concise. The handyman is still to be Legionnella trained and this could lead to service users being at risk. The accident book is not up to data protection requirements but all incidents are logged and dealt with. EVIDENCE: There is no formal system in place to survey service user and visitor comments and views. Service users and relatives spoken with said that they had not been formally asked for their views about the home. However one person said she ‘could make her views clear’ and another person said he felt confident to Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 16 ‘speak to Sue (the manager) if he wasn’t happy. A copy of the last inspection report was prominently displayed. The Administrator keeps accurate records of service users’ finances and all have individual records. Records are seen by the relatives and residents and receipts clearly show any money spent or received. All service users’ money is kept separately. The home’s maintenance records are seen and all relevant checks and drills are shown and are up to date. These include call system checks, boiler test, electricity checks. There is no evidence of the handyman’s legionnella training. The accident book does not contain the appropriate forms to adhere to data protection requirements. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X 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 4 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 3 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 3 3 X 3 x Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 18 Are there any outstanding requirements from the last inspection? 1. Reg 16 OP26 Laundry arrangements to be addressed and further advice sought with regards to environmental hazards. A risk assessment must be put in place to reduce the risk of cross contamination. 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 26 Regulation 16 Requirement Clarify the advice from Environmental Health as regards the laundry arrangements and take appropriate action. Provide for consultation with service users and their representatives Timescale for action 10/11/05 2 33 24 10/11/05 Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 19 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 3 Refer to Standard 7 35 38 Good Practice Recommendations Date all elements of service user care plans. Ensure that any monies withdrawn has a clear destination with receipts and countersignatures. The accident book should be in accordance with the data protection act regulations. Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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 Beauvale Care Home DS0000040350.V257889.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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