CARE HOMES FOR OLDER PEOPLE
Beddell House Sherburn House Sherburn Hospital Durham DH1 2SE Lead Inspector
Michaela Griffin Unannounced Inspection 31st January 2006 10:30 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 Beddell House DS0000007455.V275977.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. Beddell House DS0000007455.V275977.R01.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.V275977.R01.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 in 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. The home also has its own minibus. At the time of the inspection, there were 53 people living in the home. Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspectors spent one and a half days at the home. The manager, staff and people who live in the home were interviewed. Paperwork and files were 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.V275977.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 Beddell House DS0000007455.V275977.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): 1 Information about the home is available for people considering moving in EVIDENCE: Paperwork, including the files of people who have recently moved in to Beddell House, was examined. New residents were interviewed. The home has a clear statement of purpose, and the latest version was available for inspection. Prospective service users and relatives are invited to visit the home. Beddell House DS0000007455.V275977.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): 7,8 and 10 Service users’ needs are outlined in care plans, but these are not reviewed regularly. Residents feel that the care staff treat them with respect. EVIDENCE: The care plans of 8 service users were reviewed and three people, who had lived in the home for some time, were interviewed. The home operates a key worker system. This means that a named carer is usually responsible for reviewing each person’s care plan monthly. Carers work in teams, which helps ensure continuity,when a member of staff is off work or leaves. Care teams get to know a small group of service users well and can talk to them about their needs and interests. The service users said how kind and helpful the care staff are and gave examples of named workers taking an interest in them. However, not everyone has a key worker. The needs of many of the people who live in the home are increasing, as they get older. The care plan review records are not detailed enough to show that this is considered regularly. They tend to describe people’s life styles, rather than their needs and the way that care is provided. They are not linked to ongoing risk assessments. Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 Page 9 The review process should be more thorough, with a greater focus on individual needs and outcomes. A senior carer should check and sign these reviews each month and the manager should do a regular audit, to make sure that they continue to include all the information required to ensure that people’s changing needs are met. Visits from health care professionals to the home are recorded on file. Most of the people interviewed said that they felt that their health care needs were being met. One service user described how her GP visits her every week to monitor her condition, and how the staff will send for him if she is ill. Another explained that nurses visit to change her dressings. However, some did not feel that they got enough attention for health related matters, including sensory, dietary and mobility problems. The people who live in the home said that, almost without exception, the staff treat them with great respect and consideration. Their right to privacy is recognised. Each person has their own bedroom and bathroom, as well as a sitting room, where they can entertain visitors, if they choose. Staff always knock before entering people’s rooms. Beddell House DS0000007455.V275977.R01.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): 15 Service users enjoy a good choice of meals, provided in very pleasant surroundings. EVIDENCE: Service users and an assistant chef were interviewed and menus were examined. The home provides three choices at meal times, and most people interviewed talked favourably about the quality and selection of meals offered, on the main menu. The assistant chef explained how people with unusual preferences could be catered for. As well as the three main meals a day, people confirmed that they are regularly offered drinks and snacks, and that fresh fruit is always available. The home’s dining facilities have just been refurbished, with new décor, carpet, curtains and furniture. People can choose to eat in the large dining room, or, with more privacy, in a less public separate dining area. Some people chose to have their meals served in their rooms. There is also flexibility about meal times, and service users can arrange to have a meal saved or served early. . Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 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 Some people in this home are not confident about making complaints or expressing their concerns. EVIDENCE: The home has a clear complaints procedure. It also has a suggestions box, which people can contribute to anonymously and has a residents’ committee that meets several times a year. However, some of the people interviewed said that they would not feel confident about making a complaint, expressing their views directly to the home’s management or asking questions. Some did not feel that their suggestions were acted upon and a few did not understand aspects of the terms and conditions of their contracts. Many of the residents, of Beddell House, have relatives and friends who visit regularly and who can represent their wishes and concerns to the home’s management, if required. Some also have contact with their own solicitors. But, there are some individuals who do not have anyone to represent and support them in this way, and who would benefit from access to independent advice and advocacy. The home should establish a link with a service offering independent advocacy, representation and confidential advice to older people, and display contact details on notice boards. This information could be included in the service user guide. Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 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): 24 and 26 The home is kept clean and tidy, and people’s own rooms are safe and comfortable. EVIDENCE: Communal areas were inspected and some service users invited the inspectors to visit them in their own rooms. The residents all have their own suite of rooms, with their own furniture, ornaments and pictures. The rooms are individual and most people were very satisfied with their own accommodation and its location in the building, on one of three floors. Some rooms have larger windows and their residents enjoy a pleasant view of the grounds, driveway or open countryside. Those who wish to, can request a move, when an alternative room becomes available There are pull alarms in all the rooms. And, the home provides pendant alarms for some residents, based on an assessment of their risk of falling. The home is moving to a new system of radio-activated pendant alarms for residents who are assessed as needing them. These service users will be able to summon help wherever they need it.
Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 Page 13 The communal areas are clean and tidy and the only odours are pleasant. Beddell House DS0000007455.V275977.R01.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): These standards were not assessed at this inspection. EVIDENCE: Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 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 and 35 The home is developing effective quality systems. Service users control their own money and most have solicitors, bank managers or family to assist them. EVIDENCE: The service users who were interviewed had their own bank accounts and controlled their own money. Some sought the advice of their own solicitors and banks, but a few lacked information about charges, possible tax credit and pension entitlements, and may benefit from independent advice. The home has a very basic quality assurance system based on regular visits and reports, from a member of the board of governors and a suggestions box for residents. Comment cards, provided by the Commission for Social Care Inspection (CSCI), are available in the entrance to the home. The manager is developing a quality assurance and monitoring system, which should include regular, anonymised surveys of residents and visitors and will
Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 Page 16 seek the views of professionals. These will be combined into an annual quality report, which will be made available to the governors, current and potential residents and the CSCI. Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 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 3 x x x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 x 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 x 18 x x x x x x 3 x 4 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x x 2 x 3 x x x Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 Page 18 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 OP7 Regulation 15 Requirement The home must revise its procedures to ensure that care plans are reviewed fully, on a regular basis. The home must establish and maintain a system for reviewing the quality of care provided, including the views of service users and their representatives Timescale for action 01/06/06 2 OP33 24 01/10/06 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 Refer to Standard OP16 Good Practice Recommendations The home should review its practice in inviting and responding to complaints, comments and queries and enable service users to have access to independent advice, advocacy and representation. Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 Page 19 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. Extracts may not be used or reproduced without the express permission of CSCI Beddell House DS0000007455.V275977.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
