Inspection on 25/07/05 for Beech Close Care Home

This inspection was carried out on 25th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

Beech Close Care Home 20/09/07

Beech Close Care Home 24/04/06

Beech Close Care Home 16/01/06

Beech Close Care Home 16/11/04

Similar services:

Trevayler Residential Care Home

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

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

CARE HOMES FOR OLDER PEOPLE Beech Close Care Home Beech Close Desborough Northants NN14 2NP Lead Inspector Kathy Jones Unannounced 25 July 2005 @ 07:50 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 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. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beech Close Care Home Address Beech Close Desborough Northants NN14 2NP 01536 762762 01536 762313 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Shaw Healthcare (De Montfort) Ltd Mrs Rose McClarnon Care Home Only 42 Category(ies) of Older People (OP) 42 registration, with number Dementia - over 65 (DE(E)) 12 of places Physical Disability (PD(E)) 6 Mental Disorder (MD(E)) 7 Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. All re-development work detailed in the refurbishment plan submitted to the Commission on 25.04.04 must be completed by March 2009. 2. No one falling within the category of DE(E) may be admitted into the home where there are 12 service users who fall within the category of DE(E) already accommodated within the home. 3. No one falling within the category of PD(E) may be admitted into the home where there are 6 service users who fall within the category of PD(E) already accommodated within the home. 4. No one admitted for intermediate care may be accommodated outside of the designated intermediate care unit. 5. No one falling within the category MD(E) may be admitted into the home where there are 7 service users who fall within the category of MD(E) allready accommodated within the home. 6. Service Users within the category MD(E) can only be accommodated in the area designated as flat 1 bedrooms 1 to 7 as detailed in the plan submitted to the commission on 04.01.05. 7. No one falling within the category of MD(E) can be accommodated in any room outside of the area designated as Flat 1. Date of last inspection 16/11/04 Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 5 Brief Description of the Service: Beech Close is a home providing personal care to 42 service users in the old age, dementia, physical disability and mental health categories. The home is owned by Shaw Healthcare (De Montfort) Ltd. Beech Close is in a residential area of Desborough and is close to local facilities and amenities. The premises were purpose built some years ago and provide single rooms and a range of communal areas for the service users. These include small lounge areas within the 6 accommodation areas known in the home as ‘flats’ and ‘the Street’ area offering a variety of services including hairdressing, tea bar, library and shop. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 6 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over approximately four hours on the morning of a weekday. Prior to the inspection the Inspector spent one and a half hours reading the last inspection report, the homes service history and a comment card submitted by a relative. This information was used to plan the key areas to be inspected. Pre-inspection information is submitted by the home at least once a year however on this occasion this was not requested. The inspection involved talking to Residents about their life in the home and reviewing a sample of records to see how their care is planned and supported. The Inspector met with a group of Residents and Staff over coffee in the new mental health unit to discuss their life in the home. Two Residents rooms were seen on one of the other units by agreement with them and daily routines discussed with Staff. Training records were briefly reviewed and discussed with the Registered Manager and a member of Staff. The Registered Manager had a pre-arranged appointment however was available for feedback from the inspection and brief discussion regarding improvements made. Observations of the interactions between Staff and Residents were made throughout the inspection and noted to be positive. What the service does well: There was a very friendly atmosphere in the home and all Staff were seen to greet Residents as they passed by. One Resident said he liked to sit in the ‘street’, which is a communal area of the home on the ground floor to see the comings and goings between units. Residents confirmed that routines in the home are flexible and staff kind. Staff spoken to appeared knowledgeable about the preferences of individual Residents and demonstrated an active interest in their welfare. Staff spoken to appeared committed to further training and continued improvements in the standards of care provided to Residents. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 7 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. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 8 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 Standards Statutory Requirements Identified During the Inspection Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 9 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 standard(s) 3 Failure to use the information gathered during the assessment to develop care plans provides no assurances that Residents needs are going to be met. EVIDENCE: Records for a recently admitted Resident were sample checked which identified that an assessment carried out by the Local Authority had been obtained which detailed previous medical history and care needs. A copy of the care agreement with the Local Authority had also been obtained. The information gathered during the assessment process had not been used to develop care plans to guide and instruct Staff in meeting Residents needs. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 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 standard(s) 7, 8 and 10 The lack of care planning and risk assessment in the mental Health Unit provides no assurances that Residents needs will be met and has the potential to put Residents and Staff at risk. EVIDENCE: A sample check of a Residents file that the company has a comprehensive system of care planning. However a sample check of records for a Resident admitted to the new Mental Health Unit, which was opened in April 2005 identified that no care plans or risk assessments were in place for any of the Residents on that unit to guide and instruct staff in providing care and managing risks appropriately. The Inspector was told that trained staff from one of the companies other homes are due to visit the home to advise on mental health care plans however the Manager acknowledged that it is not acceptable for Residents to be admitted without care plans and risk assessments. There was no evidence in the records of health care planning or arrangements for Residents to receive appropriate health care services however a member of Staff told the Inspector that a Community Psychiatric Nurse was due to visit Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 11 Residents and daily notes showed that a Resident had seen a General Practitioner. Following the inspection the Registered Manager has confirmed that risk assessments have been put in place and care plans are being developed. During the inspection Staff were noted to be mindful of Residents privacy and dignity. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 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 standard(s) 12 and 14 Staff are making every effort to ensure that Residents lifestyle matches their expectations and preferences. EVIDENCE: Discussion with Residents and Staff on the Mental Health Unit confirmed that Staff are actively working with Residents to identify activities which are of particular interest to the individual. Staff were enthusiastic and understood the importance of providing stimulating activities relevant to the individual. Care plans need to be developed based on this initial work carried out by Staff. The Manager advised that an Activities organiser for the home is to be appointed. Routines in the home were observed to be relatively flexible. Breakfast is organised on the individual units and Staff were seen to be serving breakfast as and when Residents were ready. Staff spoken to had a good understanding of the preferred routines of individual Residents and were encouraging independence and choice. Staff from all departments were observed to be taking the time to have brief conversations with Residents and ask how they were as they went about their duties. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 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 standard(s) 18 Action is taken to protect Service Users from abuse. EVIDENCE: A sample check of staff training records identified that some staff have had Protection of Vulnerable Adults training. The Registered Manager advised that further training is planned for all staff, which will include whistle blowing. Discussion with the Registered Manager confirmed that appropriate action has been taken to refer allegations of abuse under Protection of Vulnerable Adults procedures for investigation. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 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 standard(s) 20, 24 and 25 The premises are clean and comfortable with plans for further improvements however risks relating to heating appliances need to be reviewed. EVIDENCE: The company have plans to carry out refurbishment of the premises. A full tour of the premises was not carried out during this inspection however communal areas of two units were seen. Areas of the home seen were clean and tidy. The home is divided into six separate units each unit having a communal lounge and kitchen area. Facilities are available for those who are able to make drinks on the units and staff were preparing and serving breakfast and morning drinks on the individual units. Smoking is not allowed on the individual units. For those Residents who smoke there is an area on the ground floor, which they can use, which doesn’t impact on other Residents. A Resident confirmed that the home was comfortable and that she was on the whole satisfied with her room. The room was rather dark due she felt to the Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 15 height of the hedging blocking the light however she has asked for this to be addressed and was confident that the matter would be dealt with. The Manager advised that maintenance Staff have been employed and it is intended that these issues will be dealt with. Residents are encouraged to personalise their rooms by bringing in personal possessions. A Resident told the Inspector that a free standing radiator had been purchased to use in her bedroom during the winter as the room is quite cold. The Manager was advised to carry out a full risk assessment and to seek advice from the Fire Officer. A previous requirement relating to a worn carpet has been met. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 Staffing levels and Staff training are kept under review in order to meet Residents needs. EVIDENCE: Comments from Staff and a relative and discussion with the Registered Manager identify that improvements have been made in the staff hours allocated for caring. The practice of care staff carrying out domestic tasks has ceased giving them more time for Residents. The Manager is also trying to recruit Staff to prepare and cook teas to ensure that care staff hours are dedicated to Resident care. Staff records were not fully reviewed during this unannounced inspection as the Manager had a pre-arranged appointment out of the building. Discussion with Staff, review of staff training records for two senior staff and discussion with the Manager confirmed that action has been taken to address previous requirements regarding Staff training. Staff involved in the new mental health unit have received mental health awareness training, advice was given for at least senior staff to carry out some more in depth training. Eight staff are currently working towards a National Vocational Qualification training and three more are due to start. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) This section of the standards was not reviewed during this inspection. This section of the standards was not reviewed during this inspection. EVIDENCE: This section of the standards was not reviewed during this inspection. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 x 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION x 3 x x x 2 2 x STAFFING Standard No Score 27 3 28 2 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 x x x x x x x x Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 19 Yes Are there any outstanding requirements from the last inspection? 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 3, 7, 8 Regulation 12 (1) (a & b), 13 (4) (c ), 15 (1) 12 (1) (a &b) Requirement Timescale for action 30.08.05 2. 8 3. 25 13 (4) (c ), 23 (2) (p) Care Plans and Risk assessments based on a full assessment must be in place for all Residents. (previous requirements have been made regarding the further development of care plans) Records must be in place to 30.08.05 identify Residents health care needs and include details of all relevant health professionals and services. The use of free standing heating 30.08.05 appliances must be reviewed and appropriate action taken based on a full risk assessment and advice from the Fire Officer. 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 30 Good Practice Recommendations More in depth training in mental health should be undertaken by Senior Staff resposnible for the mental health unit. Beech Close Care Home C51 C08 S60165 Beech Close V235650 250705 Stage 4.doc Version 1.40 Page 20 Commission for Social Care Inspection Northampton Area Office 1st Floor, Newland House Campbell Square Northampton, NN1 3EB 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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