Inspection on 16/02/06 for Beddell House

This inspection was carried out on 16th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beddell House 02/10/08

Beddell House 04/10/06

Beddell House 31/01/06

Beddell House 25/11/04

Beddell House 22/07/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Beddell House Sherburn House Sherburn Hospital Durham DH1 2SE Lead Inspector Michaela Griffin Unannounced Inspection 16th February 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 Beddell House DS0000007455.V282732.R02.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. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beddell House Address Sherburn House Sherburn Hospital Durham DH1 2SE 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) 0191 3720421 0191 3720035 The Corporation of the Master and Brethren of Christ`s Hospital Miss Joanne Lisa Carr Care Home 62 Category(ies) of Old age, not falling within any other category registration, with number (62) of places Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th November 2004 Brief Description of the Service: Beddell House is a residential care home, with accommodation for up to 62 people on three floors. It is a very attractive old building, with an interesting history. It is set in its own large grounds, with a church and sheltered housing on the same site. Its location is rural, a few miles outside Durham City. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two inspections which, between them, looked at all the key standards for homes for older people. Two inspectors spent two half days at the home. They talked to the manager, four members of staff, two relatives and five residents. The manager was interviewed and paperwork was checked. 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. Beddell House DS0000007455.V282732.R02.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 Beddell House DS0000007455.V282732.R02.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 The home carries out an assessment of people who want to move into this home, or offers them a trial visit. EVIDENCE: The files of 8 service users were checked. These included two people who had recently moved into the home, one of whom was interviewed. Many of the people who move into Beddell House do not have a social worker, so the home does not obtain a care manager’s assessment for every prospective resident. People who are interested in moving into the home are encouraged to visit and are offered a trial stay, to help them and the manager decide if Beddell House can meet their needs. The manager visits people who live locally before they move in, and carries out her own assessment of their needs. However, the manager does not always visit prospective residents, if they live further than easy travelling distance away. When it is not possible for the manager to a home visit. An assessment should be requested from suitably qualified professionals in the applicant’s area, so that people can be assured that the home can meet their needs, before they move in. This is important when people are considering leaving the communities they know, as well as their own homes. Beddell House DS0000007455.V282732.R02.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 and 9 Service users’ needs are outlined in care plans, but these are not reviewed regularly. Service users are protected by the home’s policies and procedures for the handling of medication. EVIDENCE: The manager, care staff and service users were interviewed. Paperwork was checked. The last inspection found that the care plan reviews are not detailed enough to show that changes in need are considered regularly. The manager has not been directly involved in the review process or in asking service users about their needs and how the service is provided. The residents interviewed could not confirm that they were asked regularly if they are happy with the service, if their needs had changed and if they would like their care provided in a different way. However, the manager has already begun to improve the care planning process, in the way required by the last inspection report. Many of the people who live in this home continue to take responsibility for their own medication, the home’s procedures and facilities enable them to do so safely. Senior care staff, who administer medication, have received training Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 9 in the safe handling and storage of medication. The deputy manager, who is a qualified nurse, is responsible for overseeing and auditing the processes. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 10 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 and 14 The home welcomes visitors but it does not provide a wide enough choice of activities and outings, to suit the tastes and ability of all residents. EVIDENCE: People who live in the home, relatives and staff were interviewed. The activities programme and notice boards were checked and the activities, going on in the home, observed. Relatives interviewed said that they felt that they were welcome to visit Beddell House at any time. They remarked on how friendly the staff are and how they are happy to talk to them. A relative said ‘The carers keep me informed about the day to day details of my mother’s life. They are so good, I am so impressed.’ Some people have visitors several times a week and some visitors also attend social events organised at the home. One explained ‘I come every day, to see how he is.’ Some of the residents who lived locally, have maintained links with organisations they were involved in, before they moved to the home. The home has a mini-bus, which is available for planned outings. Unfortunately, Beddell House’s location makes regular, individual, contact with the community, family, friends and neighbours difficult. One lady’s neighbour had visited her for years, but he could no longer do so once he was unable to drive. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 11 The home has a programme of activities, including a twice-weekly exercise class, a painting group and bingo sessions. There are also regular shopping trips, in Beddell House’s own mini-bus, and periodic outings to the theatre. The home also invites schools and community groups in to provide entertainment and there were a series of social events leading up to Christmas. People who live in the home, and visitors, had good things to say about activities that have been organised in the past and social occasions they have enjoyed. However, some activities and outings planned by the home are not well supported by residents. People who live in the home said that this is because the entertainment on offer does not suit their taste or ability. Some people do not feel up to sitting through a whole production at the theatre and some do not like going shopping every week. Residents commented that they would prefer it if day trips were more frequent and not only during the summer. One said ‘I would love to go for a ride to the coast, there is nothing much on here.’ Within the home, some would prefer more classical entertainment. Others, who are not independently mobile, said that they would like to be taken out in the grounds by staff, but do not ask them because they are so busy. People, who do not have family or friends who can visit, said that they sometimes feel isolated. Some sit in their rooms most of the time, entertaining themselves with television, crosswords and reading. Residents said that the home’s chaplain visits church-goers regularly, but that there does not seem to be an equivalent or volunteer visitor service for other residents. Comments were also made that there is little on offer for the more frail and less independent residents. The home should employ an activities’ organiser, or give a member of staff specific responsibilities for consulting residents about their preferences and organising a programme of activities to match them. This may help to ensure that the lifestyle offered by the home, satisfies the tastes and range of needs of all residents. Consideration should be given to finding activities to suit the more frail and less able residents, and to providing individual attention and support to enable them to join in. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 12 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): 18 The home’s policies and procedures for the protection of vulnerable adults are not up to date. EVIDENCE: Paperwork was examined and staff were interviewed. Staff files confirmed that the home follows robust procedures in the recruitment of staff, ensuring that references are received and police checks are carried out, before the individual appointed starts work. The home has long established policies and procedures, for the protection of older people from abuse. Staff interviewed also demonstrated that they are aware of the signs and symptoms of abuse. And, they would have no hesitation in reporting any concerns or suspicions they had to the home’s management. However, the home’s polices and procedures have not been reviewed recently and do not take into account changes in national and local policy and practice. Staff were not aware of the lead role of local authority social services departments in investigating abuse allegations, or of the local multi-agency policy. The home’s policy and procedures must be revised, to be consistent with the County Durham and Darlington Strategy for Safeguarding Adults. And, all staff must receive regular training, so that they know what to do if they suspect a vulnerable adult is being neglected or abused. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 13 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 People in Beddell House, live in a safe well-maintained environment EVIDENCE: The home is furnished and fitted to very high standards. There is a programme of routine repairs and maintenance, as well as regular refurbishment and redecoration. A maintenance manager is based on site, and he is responsible for ensuring fire and safety checks are carried out and recorded. The external space is also well maintained and pleasant to sit or walk in. The grounds are laid out with safe paths, between lawns, trees and flower beds. And, there are places for residents and visitors to sit outside. The home has a limited number of electric wheelchairs, for less mobile service users who want to enjoy the grounds. There is ample car parking for visitors. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 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 Service users are in the safe hands of staff who have been carefully vetted and well trained to provide their care. EVIDENCE: The people who live in this home said many complimentary things about the care staff. They described how hard they work, how helpful they are, how they know their jobs well and have the skills to carry them out. Some service users mentioned that they feel that their key workers are very patient and take a personal interest in them. One resident said ‘the girls are all good and always have been.’ Another commented: ‘they are all kind.’ Relatives were also pleased with the care staff. One explained: ‘I am hugely impressed by the carers, their patience and cheerfulness.’ Another said ‘I think the best thing is the care provided by the carers.’ Unfortunately, not every service user has a key worker. Some of the residents look after themselves, and do not need assistance from staff. They explained that, although the carers do not usually have time to sit and chat, they are quick to respond, if they ring for help. Those who are able to prefer to be independent and the home encourages this. However, some people remarked that the home now has more residents who need help with personal care and that most of the carers’ time is taken up with attending to their physical needs. Care staff also do laundry. Some service users, who can do most things for themselves, suggested that they would like more attention from staff, but realise that they are too busy. A relative also expressed the opinion that there are not always enough staff on duty. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 15 Personnel files were examined and they showed that the home ensures that all staff are thoroughly vetted before they are appointed. New staff have a period of induction, while they learn how to provide care safely and to follow the home’s routines. There is also an annual training programme. Most of the care staff have already achieved at least level two NVQ in care. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 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 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): 31,36 and 38 The home is well managed. EVIDENCE: Records were checked and staff were interviewed. Service users and relatives were asked for their opinions of the service, by interview and comment cards. The manager of Beddell House is established in her post, with many years of relevant experience. She is a qualified nurse and has an appropriate management qualification. However, several people commented that they were disappointed that the manager does not spend more time chatting to, and getting to know, service users. Staff receive supervision from either the manager or her deputy and both have had relevant training. However, this has not been carried out as frequently as the standards recommend. The manager should consider delegating more of the responsibility for supervising care staff, to senior carers, who should be given the appropriate training and guidance. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 17 All staff receive training in safe working practices and checks are carried out routinely. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 x 9 3 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 x 18 1 4 X X X X X X X STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 x x x x 2 x 3 Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 Requirement Timescale for action 01/06/06 2 3 OP7 OP12 15 16 4 OP18 13 (6) The home must revise its admission procedures to ensure that accommodation is not provided without the needs of the service user having been assessed, by a suitably qualified or suitably trained person. The home must continue to 01/06/06 improve its care planning and review processes. The home should extend its 01/10/06 programme of activities to suit the needs and preferences of all service users The home must revise its policies 01/05/06 and procedures for safeguarding vulnerable adults, to take into account developments in national policy and the local multi-agency strategy. The home must also include training for all staff, in the latest procedures and good practice, in its training programme. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 20 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 OP36 Good Practice Recommendations The manager should ensure that all staff receive regular supervision from a person who is suitably trained to provide it. Beddell House DS0000007455.V282732.R02.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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. 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