Inspection on 03/10/06 for Beauvale Care Home

This inspection was carried out on 3rd October 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 15/02/06

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 Karmon Hawley Key Unannounced Inspection 3rd October 2006 10:00 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.V310966.R02.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. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 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 www.southerncrosshealthcare.co.uk 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.V310966.R02.S.doc Version 5.2 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 February 2006 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. 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. The manager said that the previous inspection report is made available to all prospective service users prior to making a decision to moving into the home; this is located in the main foyer. The manager stated that the current weekly fees are as follows: residential £475, nursing £495 plus free nursing care contribution. The cost of hairdressing and chiropody is not included in the fees. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the site visit an analysis of the performance of the home over the previous year took place in line with the key national minimum standards. The evidence gained was assessed and the site visit planned in accordance with further evidence required to demonstrate compliance with the national minimum standards. The unannounced site visit took place in five and three quarter hours and was performed by one inspector. The main method of gaining evidence during the site visit was case tracking, this is a method of sampling the records of four randomly selected service users to ascertain if the needs of service users are appropriately assessed and identified needs are being catered for by the home to maintain optimum health and wellbeing of the service user. Seven service users were spoken with so as to give the inspector an insight into the conditions and standards within the home. Those spoken with were generally happy with the staff, care received and the standards within the home. The registered manager assisted in the inspection process and two members of staff were spoken with. Staff were able to demonstrate an understanding of service users needs and the core values and principles in relation to their job role. What the service does well: What has improved since the last inspection? What they could do better: Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 6 To ensure service users needs are fully met in an appropriate setting the arrangement for reassessment of two service users is required. To ensure appropriate risk assessments are in place for all highlighted risks to ensure service users are fully protected. Demonstrate that sufficient staff are provided at all times to meet the needs of service users. Nine good practice recommendations were also made which are discussed in the main body of the report. 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.V310966.R02.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 Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 The quality rating for this outcome area is adequate. This judgement was made using evidence available including a visit to the service. Although service users needs are assessed prior to admission their needs may not be fully met due to being admitted out of category. The home does not provide intermediate services. EVIDENCE: The manager visits prospective service users in the community prior to admission and carried out a preadmission assessment, which covers the requirements of this standard. Prospective service users and relevant others may also visit the home and spend time there prior to making a decision to move in. Staff spoken with confirmed that this takes place. On observing service users case files it became apparent that several service users have dementia care needs, the home is not registered to care for service users within this category. Intermediate services are not offered. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 9 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 The quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. Service users health, personal and social care needs are set out in a plan of care, however Service users health care needs are met. Service users are protected by the homes medication policies and procedures. Service users feel they are treated with respect and their right to privacy is upheld. EVIDENCE: Service users case files seen demonstrated that they undergo various assessments such as the activities of daily living, pressure area care, nutritional needs and manual handling. Information gained forms the plan of care. Plans of care in place were in depth and covered highlighted needs, however in a number did not fully reflect personal choices and preferences. Reviews were taking place, however were not service user focussed and did not fully reflect current and changing needs. Daily records were maintained and contained details of significant events. Risk assessments were in place for most highlighted risks, however within one plan of care a risk assessment for a different service users was in the file, therefore no risk assessment for Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 10 entrapment was available. Also for a service user wearing a lap belt there was no consent form for this or risk assessment for entrapment. One service user at risk of falls did not have a risk assessment in place. Staff spoken with were able to discuss the use of risk assessments and said they were aware of the risks service users may encounter. Service users spoken with stated that their needs were met, however two stated that they had to wait for periods of time to get attention. Staff spoken with were able to discuss service users needs. A GP surgery is held every week so service users may see a doctor if needed, also visits on request are arranged. One service user spoken with confirmed this. The manager stated that the district nurse supplies relevant equipment for residential service users and the home provides this for nursing service users. Equipment such as specialist mattresses and cushions were seen during the tour of the building. Appropriate medication policies and procedures were seen. Medicines were signed into the building when received. The medication and service users prescription were checked, these corresponded. Room and fridge temperatures were available. Eye ointment was not dated when opened. The services’ philosophy of care includes ensuring that service users privacy and dignity are upheld. The manager stated that staff are instructed to knock on service users doors prior to entering, all doors have knockers in place. One service user spoken with confirmed this. All service users spoken with stated that staff were respectful at all times. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 11 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 and 15 The quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. Service users find the lifestyle experienced in the home matches their expectations and preferences. Service users are enabled to maintain contact with relevant others. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome and appealing diet in pleasing surroundings. EVIDENCE: There is an activities coordinator employed five days a week. Activities are provided in both group sessions and on an individual basis. The activities on offer were displayed and were varied. There is also a monthly newsletter circulated which offers up to date news about the home. Service users spoken with stated that they were happy with activities on offer and there was enough for them to do. Several spoke about the dominoes league and the fun they have, others expressed they enjoyed the trips out of the home. Service users were seen playing bingo on the day of the inspection. There is a rota for the local churches that visit the home on a monthly basis; one service user spoken with confirmed this and also said that they could go to church if they wished. There are no restrictions imposed on visiting. There is a keypad code to the main entrance and the manager stated that regular visitor have access to the Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 12 number, staff spoken with confirmed this. Should a service users wish to leave the home they also may have the code if appropriate. Service users spoken with stated that they are able to receive visitors at any time and these may be received in private. Staff spoken with discussed how they aim to ensure that service users are offered choices in their daily activities and that these are upheld. They also discussed how they ensure individual care is offered and service users are recognised for their own personality and needs. Service users spoken with said that staff were respectful and that good relations were maintained. There is a payphone for service users to use if required, a number of other service users have their own line or mobile phone. There was evidence seen within one service users care plan that showed that an advocate had been used. A wholesome and appealing diet is on offer, choices are offered at breakfast and tea; one main meal is offered at lunch however alternatives are available. A board in the kitchen showed service users likes, dislikes and preferences. Service users spoken with said meals were generally of a good standard and were plentiful. Relevant records such as cleaning rotas and temperatures were seen. There were a number of gaps in the cleaning rota, the manager stated this was when care staff may have been covering in the kitchen and she would address this. Following a recent Environmental Health Officer visit seven points were raised in regards to cleaning, ventilation, the fly screen and work surfaces, the manager stated that five of these have been actioned and the remaining two are being addressed. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. Service users and relevant others may be assured their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: Relevant policies and procedures were seen for dealing with complaints. There have been no complaints received since the previous inspection. Staff spoken with were able to discuss how they would deal with a complaint should it be received. Service users spoken with were generally satisfied with life within the home and care received, however two service users stated that on occasion they had to wait for period of time for attention due to staff shortages. This is discussed further in standard 27. Relevant policies and procedures for adult protection were seen. Staff files seen demonstrated that all staff have satisfactory Criminal Record Bureau checks in place. Staff training records seen showed that 63 of staff have undergone adult protection training. Staff spoken with were able to discuss relevant issues with the inspector. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26 The quality rating for this outcome area is adequate. This judgement was made using evidence available including a visit to the service. Service users live in a safe well-maintained environment. Service users live in a clean and pleasant environment however further consideration to the relocation of the laundry facilities is recommended and attention is required in regards to hand wash facilities in the laundry area to ensure effective infection control is maintained. EVIDENCE: Records of maintenance servicing such as wheelchair checks, bedrail checks and window restrictor checks were seen. Several service users rooms have been redecorated. A developmental plan, which had been discussed with the manager and regional manager was seen, there are plans to further develop the home and continue with redecoration and replacement of furniture. The laundry room remains as previous, however the kitchen door was kept shut. There was evidence seen in the development plan to show that consideration is being given to move the laundry facilities. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 15 There were no hand washing facilities in this area, staff stated that they use a hand wash facility located the other side of the dining room. One service user spoken with stated that their room is kept nice and clean. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 and 30 The quality rating for this outcome area is adequate. This judgement was made using evidence available including a visit to the service. Service users needs may not be fully met by the number and skill mix of staff when experiencing a busy period, therefore contingency plans in the event of this occurring would be beneficial. Staff are working towards ensuring service users are in safe hands at all times. Service users are supported and protected by the homes recruitment policies and practices. Staff are working towards ensuring they are trained and competent to do their jobs. EVIDENCE: The duty rota was seen. One registered nurse, one senior carer and four care assistants are on duty during the day. One registered nurse and two care assistants are on duty during the night. There was evidence of sickness occurring, however this had been covered. On speaking with two service users they said that they had to wait long period of time to get attention. This was discussed with the manager and two members of staff. The manager was aware of one service users opinions and said that she had discussed this further with them and their relatives. Staff spoken with stated that in general there was enough staff available to meet service users needs, they had been busy during the day of the inspection due to the visiting chiropodist. When speaking with service users the inspector observed that two had not had a shave and one had breakfast on their face and stained clothes from breakfast. On discussing this with staff they stated that today had been Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 17 extremely busy and was not a usual day and this was not normal practice. Also service users are asked if they wish to have a shave and if declined this would be accepted. Staff said that more time to care for those with dementia care needs would be beneficial as if they were unsettled this could impact upon care delivery. Three members of staff have achieved the National Vocational Qualification (a work and knowledge based qualification based upon nationally recognised standards) level 2 and two have achieved level 3 a further 5 members of staff have signed up to commence level 2. All new staff undergo an induction, this currently consists of 2 days where issues such as the company, service users needs and staff needs are covered. The manager stated that she is looking to improve this in the near future. Staff files seen showed that staff are undertaking induction. The staff training matrix seen demonstrated that staff are working towards completing training in all mandatory areas. There is outstanding training in health and safety and food hygiene, however the manager said that these were to be addressed. Staff spoken with stated that they felt supported in their training needs. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35 and 38 The quality rating for this outcome area is good. This judgement was made using evidence available including a visit to the service. 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 her responsibilities. The home is run in the best interest of service users. Service users financial interests are safeguarded. The health, safety and welfare of service users and staff is protected however it may be compromised due to the noted deficits. EVIDENCE: The manager has now been in post for two and a half years. She is a registered nurse and is working towards the registered managers award. She stated that she felt supported by the regional manager. Staff spoken with stated that the manager was supportive and available when needed. The manager carries out monthly audits that cover a wide range of areas such as the kitchen, pressure area care, accidents, the environment, and nutrition. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 19 Questionnaires are also sent to service users and relevant others on an annual basis. Seven completed questionnaires were seen, the responses were mainly positive. Findings from the questionnaires are published in the homes newspaper. If necessary the manager said that any negatives are discussed with the individual. Four service users personal accounts were seen; these corresponded with the accounting sheet. Two members of staff signed all transactions and receipts were available. A lockable facility is available within service users rooms. All relevant maintenance and servicing certificates were seen. Heath and safety audits were seen to take place on a monthly basis and the manager stated that a health and safety meeting is held every two months. The fire logbook seen showed that fire drills take place on a regular basis, however on one occasion it stated that staff did not attend immediately, there was no evidence of action taken following this. Emergency lights were tested on a monthly basis, however had not been tested for the month of September. Fire alarms were tested on a weekly basis however had a twelve day gap from the last test. Accident records are audited on a monthly basis which were seen Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 2 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 21 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 OP3 Regulation 14(1,a) Requirement To arrange for a reassessment of the named service users to ensure an appropriate placement is offered and their needs are fully met. Ensure appropriate risk assessments are in place for all highlighted risks. Demonstrate that sufficient staff are provided at all times to meet the needs of service users. Timescale for action 14/11/06 2 3 OP7 OP27 13(4,a) 18(1)(a) 14/11/06 14/11/06 Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 22 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 4 5 6 7 8 9 Refer to Standard OP7 OP7 OP9 OP15 OP26 OP26 OP28 OP38 OP38 Good Practice Recommendations Develop service users reviews to become service user focussed to reflect current needs and condition. Further develop plans of care to fully reflect service users personal choices and preferences. Ensure eye medication is dated when opened. Ensure the kitchen cleaning rotas are completed at all times. Ensure appropriate hand wash facilities are available in the laundry area to ensure adequate infection control procedures are maintained. To continue to explore the possible relocation of the laundry Further care staff should be supported to pursue a National Vocational Qualification to at least Level 2 in Care. Emergency lights to be tested on a monthly basis. Fire alarms are tested on a weekly basis. Beauvale Care Home DS0000040350.V310966.R02.S.doc Version 5.2 Page 23 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.V310966.R02.S.doc Version 5.2 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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