CARE HOMES FOR OLDER PEOPLE
Beddell House Sherburn House Sherburn House Durham DH1 2SE Lead Inspector
John Trainor Unannounced Inspection 4th October 2006 12:00 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.V312548.R01.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. Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Beddell House Address Sherburn House Sherburn House 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.V312548.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 16th February 2006 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 has its own minibus. At the time of inspection the range of fees was £298 - £427.25 Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and the site visit was conducted by two inspectors over 4 hours. Before the visit the home provided information on the service to inform the inspection process. The inspectors looked around the home and inspected policies, procedures and care plans. People were asked to give their views on the home. The manager and staff also gave their views. What the service does well: What has improved since the last inspection? What they could do better:
Efforts need to be made to ensure toiletries and creams are not left in communal bathrooms to assure people their own toiletries will only be used for their personal care. Razors should be stored and disposed of safely and not left in communal areas. Steradent type denture cleaners must not be left in communal areas as they can cause harm if ingested. These should be stored in a locked space. Activities should be developed based upon individual need and preference. One person said there was, “very little entertainment and bus
Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 6 outings.” The home is currently advertising for an activities coordinator to improve this outcome area. Contracts should be clear, detail fees and who is responsible for paying them. Some people expressed concern about having to hand over their attendance allowance benefit to the home. From April 2006 people newly admitted no longer have to do this, though people with this in their existing contract still do. Fees and terms and conditions should be demonstrably equitable and based on service delivered not income or receipt of benefits. Doors must not be wedged open unless by a device approved by the fire officer for this purpose. Medication records should be kept robustly, there should be a clear audit trail of medicines in and out of the home. 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.V312548.R01.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 Beddell House DS0000007455.V312548.R01.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): 1, 2, 3 and 6. Quality in this outcome area is good. People could be assured the home would assess and could meet their needs before they made a decision to move in. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Each File inspected had an assessment of need to ensure the home could meet the needs of people before they made a decision to admit. People had a copy of the statement of purpose and service user guide to inform them of the homes facilities and enable an educated choice to move in. There were contracts on peoples files though one person said they didn’t have a copy of their contract. Contracts did not clearly state fees along with detail
Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 9 of who is responsible for paying and required revision so people could clearly understand their fees and how they were constructed. The home did not provide intermediate care Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 10 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 and 10. Quality in this outcome area is good. People had their health and personal care needs met in a planned way, delivered with respect and with regard for dignity. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: All files inspected had care plans written in a style which told staff how to deliver care. There were some examples of good practice with attention to detail and accounting for dignity and people’s personal preference. There was evidence of people having their health needs met with access to doctors, district nurses and other health professionals People said they were treated with dignity and respect. Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 11 There were some gaps in recording on medicine administration record sheets staff needed to be reminded to be more robust with recording. Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 12 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. Quality in this outcome area is adequate. People had some activities and outings but would benefit from more attention to social stimulation with an activities coordinator and provision based upon individual need and preference. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: People had some outings and there was a large TV lounge where films could be shown. Menus had excellent choice and food was reported to be of good quality. Meal times included vegetables served in tureens so people could help themselves. The board of governors had approved funding for an activities co-ordinator and the job was out to advert. This should improve this outcome area. Beddell House DS0000007455.V312548.R01.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. Quality in this outcome area is good. People were protected from potential abuse and there were mechanisms to ensure their concerns would be looked at. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Information on adult abuse had been improved, staff had clear guidelines and multi agency procedures would be followed in the event of abuse. The home had policies and procedures and one complaint record was inspected. Some service users expressed worries that their complaints and concerns were not adequately addressed and they would be intimidated if they took their concerns out of the organisation. The manager kept a written record of conversations she had with people to keep a clear record of concerns and conversations. There were clear posters throughout the building advertising advocacy services if people felt they needed representation. The manager appeared approachable, polite and interested. Beddell House DS0000007455.V312548.R01.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. Quality in this outcome area is good. People had a clean and homely place to live. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home was in the main clean and tidy. One bathroom had a border which was peeling from the wall and needed redecoration. There were toiletries, razors and steradent left in communal bathrooms. People should have individual toiletries and razors and steradent need to be safely stored due to the potential of injury. Most of the rooms had door guards so they could be propped open safely. One room had damp which appeared to have been caused by water ingress and needed repair.
Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 15 Most bathrooms and toilets had liquid soaps and paper towels though one toilet did not have a soap dispenser. There were alcohol hand sanitisers around the home. The home had red dissolvable laundry bags for soiled linen. There was evidence of gloves and aprons around the home for use by staff to maximise infection control. There is a site manager who deals with environmental issues. Beddell House DS0000007455.V312548.R01.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. Quality in this outcome area is good. Staff were deployed in sufficient number and with sufficient skill to meet the needs of the people resident. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staff files inspected showed people were recruited safely with induction training and other training to enable them to meet people’s care needs. 71 of staff were trained to NVQ level 2 or above. There was a minimum of 6 staff on duty per shift. Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 17 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. Quality in this outcome area is good. The home was managed well. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The manager was well qualified, pleasant and approachable. Health and safety matters were looked after well with hoists checked electrical hard wiring checks completed, gas checks completed and fire checks and drills taking place. Fire training refreshers needed to be increased to 6 monthly for day staff and 3 monthly for night staff in line with current recommendations.
Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 18 Fire safety equipment was well maintained. Staff training was good and included moving and handling, protection of vulnerable adults and first aid. Service user money records were clear auditable and accurate. One door was being wedged open without the correct device to do so safely though evidence showed most doors had these devices fitted if people wanted them. Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 19 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 2 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 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 3 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 3 X 3 X 3 3 X 3 Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 20 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 OP12 Regulation 16 Requirement Timescale for action 31/03/07 2 OP38 23 (4(c)) The home should extend its programme of activities to suit the needs and preferences of all service users. (Previous timescale of 1st October 2006 not met.) Doors must not be wedged 04/10/06 except by devices approved by the fire officer for this purpose. Where staff notice a need to wedge doors for egress they should be reminded to raise this with the manger to allow the appropriate device to be fitted. Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 21 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 OP2 Good Practice Recommendations Contracts or statements of terms and conditions should clearly detail fees and who is responsible for paying them. It is recommended fees are structured based on care needs so there is an equitable process for deciding what individuals should pay. There were some gaps in recording on MARS sheets. Medicines should be recorded into the home to allow a clear audit trail and administration signed for robustly. 2 OP9 Beddell House DS0000007455.V312548.R01.S.doc Version 5.2 Page 22 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
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