Inspection on 15/02/06 for Beauvale Care Home

This inspection was carried out on 15th February 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 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 15/08/05

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 Meryl Bailey Unannounced Inspection 15th February 2006 11:30 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.V281668.R01.S.doc Version 5.1 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.V281668.R01.S.doc Version 5.1 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.V281668.R01.S.doc Version 5.1 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 TI. Within the total number of beds, a maximum of 3 beds maybe used for the category PD. Care Home with nursing for 35 Older People Date of last inspection 15th August 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. Bedrooms are on the ground and first floors with a passenger lift provided. There are 33 single bedrooms and 1 double bedroom. Outdoor space provides seating, part of which is covered and there is a small car park. The home is very close to the centre of the village of Bingham, making the local facilities easily accessible. Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out by one inspector during one day and lasted four hours. The inspector looked around the communal areas, but did not inspect any bedrooms in detail. The evidence was gained through speaking with service users and staff on duty. Also from observation and from examining written records. The manager and administrator were very helpful in providing information for this 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.V281668.R01.S.doc Version 5.1 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.V281668.R01.S.doc Version 5.1 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): 3 Needs are assessed prior to service users moving in. EVIDENCE: The files of the three most recently admitted service users were examined. There were pre-admission assessments followed by baseline assessments on admission. Initial risk assessments were included and led to draft care plans. Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 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 Care is planned to meet assessed needs. EVIDENCE: Information regarding three service users showed that care plans were in place except for one person who had been admitted two days earlier. This one was being prepared in draft form during the inspection. Daily notes had been written and provided clear information to hand over to other staff. The established care plans were comprehensive and based on various assessment materials. Where there was a risk of falling there were clear instructions to staff about assistance needed. Other clear plans were in place to meet needs relating to pressure sores, personal hygiene and nutrition. Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 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 and 15 A range of activities is available and balanced meals are provided. EVIDENCE: An activities worker was employed to work from 10am to 3pm from Monday to Friday each week. Service users appeared to benefit from this and some enjoyed a game of dominoes with the worker during this inspection. There was a weekly plan of events and activities and the Newsletter gave information about these. Lunch was observed and the main meal was chicken casserole and vegetables, followed by fruit flan and cream. Alternatives were seen as requested and dessert was provided to order including alternatives of mousse, peaches and ice cream. Care staff gave encouragement and assistance with eating appropriately and cutlery with grip handle was available where needed. Most service users said they usually enjoyed their food, but had to wait a long time to be served. Staff confirmed that some have to wait longer, but they alternate which tables are served first from day to day. The kitchen was small, but well organised. A cook and kitchen assistant worked together. (See standard 26 regarding the kitchen door.) Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 Page 10 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): These standards were met when assessed at the previous inspection. EVIDENCE: Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 Page 11 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): 26 The main areas of the home are kept clean by domestic staff, but there is a risk of infection as a result of dirty linen passing by the open kitchen door. EVIDENCE: The communal areas of the home were seen and found to be clean and pleasant. Housekeepers were employed to keep all areas clean and further domestic staff were employed in the laundry. As at the last inspection the laundry remained in close proximity to the kitchen. The manager had decided that action taken to reduce the risks of infected material being in contact with the kitchen or kitchen staff should be to keep the kitchen door closed. This was also the action needed when the rear outside door was open. However, the kitchen door was found propped open with the sign about risk assessment covered up by a coat. Kitchen staff said that they needed to keep the door open for ventilation. There was also a slatted screen providing some protection, but part of this was missing as it was being repaired. The risk assessment should be reviewed and appropriate action taken. The laundry itself was small, appropriately equipped and the sluice was clean and kept locked. Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 Page 12 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 and 28 There is always a trained nurse on the premises, but numbers of care staff are not always sufficient to meet needs. Some care staff have received vocational training, but more should be supported to develop their care skills. EVIDENCE: Some service users commented that there were not enough care staff during the day and they had to wait for assistance. During the afternoon of this inspection, one care assistant was transferred to the night shift and not immediately replaced on the afternoon shift. Service users were, observably, distressed whilst waiting for attention. Staffing rotas showed that the plan was to have five care staff with one nurse from 8am to 8pm and then two carers with one nurse over night. However, during this inspection, one care assistant was taken off the afternoon shift and moved to the night shift. The rotas displayed showed several gaps and the manager was asked to send in completed rotas for the following two weeks. This was done, but there were still some shifts with only four care assistants, though all nursing shifts were covered. A requirement has been made for the provider to demonstrate that sufficient staff are provided to meet the needs of all service users at all times. Of the current 35 service users, 23 had nursing needs. 5 of the 26 care staff had attained a National Vocational Qualification to at least Level 2 in Care. Further care staff should be supported to pursue this qualification. Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 Page 13 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): 31, 33 and 35 There is a registered manager and a quality monitoring system involves seeking service users views. Action is taken to safeguard service users financial interests. EVIDENCE: The registered manager was a registered nurse and was pursuing a course at level 4 of the National Vocational Qualification to attain the Registered Managers Award by December 2006. A questionnaire had been used in November 2005 to survey the views of half the service users. Only seven replies had been received and comments contained in them had received attention. Head office will collate the information and include feedback in the revised Service user Guide. There was also a monthly Newsletter, which was used to welcome new staff and residents and to announce birthdays and deaths. First names only were used. Events and activities were also detailed in the Newsletter. Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 Page 14 Service users’ money was looked after securely. Records were well maintained by the administrator and two signatures were always obtained to verify each transaction. There was a pooled account for some service users’ personal allowances to be received from the Social Services Department and changes were planned to separate each service user’s money using a particular type of bank account. This would be preferable. Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 Page 15 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X X X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X X Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 Page 16 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP27 Regulation 18(1)(a) Requirement Demonstrate that sufficient staff are provided at all times to meet the needs of service users and specifically how shortfalls are met. Timescale for action 31/03/06 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 OP26 OP28 Good Practice Recommendations Review the risk of infection from laundry passing the open kitchen door and clarify with staff the action to be taken. Further care staff should be supported to pursue a National Vocational Qualification to at least Level 2 in Care. Beauvale Care Home DS0000040350.V281668.R01.S.doc Version 5.1 Page 17 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.V281668.R01.S.doc Version 5.1 Page 18 - 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!