Inspection on 16/06/06 for Beech Court

This inspection was carried out on 16th June 2006.

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 Court 25/09/08

Beech Court 05/06/07

Beech Court 22/09/05

Beech Court 18/04/05

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 Beech Court 52 Church Lane Selston Nottinghamshire NG16 6EW Lead Inspector Jayne Hilton Key Unannounced Inspection 16th June 2006 08:00 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 Beech Court DS0000062132.V296711.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. Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Court Address 52 Church Lane Selston Nottinghamshire NG16 6EW 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) 01623 752 512 Mr Alan Peter Pearce Mrs Lesley Pearce Mr Alan Peter Pearce Care Home 23 Category(ies) of Dementia - over 65 years of age (23), Old age, registration, with number not falling within any other category (23) of places Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection Brief Description of the Service: Beech Court, 52 Church Lane Selston, Nottinghamshire is a 23 bedded, care home offering personal care for older people with dementia. The building is a converted rectory with a purpose built extension and is on two floors. There is a passenger lift to the first floor. The home has an easy accessed garden and is located in a quiet corner of the village opposite the church. Information about fees collected on 16-6-06 range from £277.00-£333.49. Extras payments are needed for hairdressing and Chiropody. The registered Provider provides a fully funded day trip out on an annual basis. Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection took place on 16th June 2006 at 8am and concluded at 3.30pm. The unannounced key inspection was carried out by, Regulation Inspector Jayne Hilton. The methodology used included the examination of four care plans, staff personal records, observation of staff practice, speaking with service users, staff and relatives. The registered provider and the care manager were in attendance for the majority of the inspection. A part tour of the building took place and various records and policies were examined. Twelve service user comment questionnaires were returned to the home and presented to the inspector at the visit and are integrated into this report. What the service does well: All service users spoken with reported that they were happy with the care provided and service users were observed to be relaxed and comfortable throughout the inspection. The Providers have many years experience in care provision and state that they have cared for service users with dementia type illness in their other care home, however Beech Court is more specialised provision and the provider is developing staff to meet the varied needs of the service users. Staff members have undertaken training in dementia care and activities for people with dementia. Service users are treated with respect and their privacy upheld and they maintain contact with family/friends/representatives and the local community as they wish. There were generally satisfactory records kept regarding outside professional input such as GP and district nurse visits. Service users and relatives were clear about making a complaint should they need to. Service users live in a clean, well - maintained environment that is currently being re-furbished to improve the quality of facilities for service users. Bedrooms meet standards and are personalised. The home was found to be clean and free from mal odour. The health and safety of service users is generally safeguarded. The meals provided are overall on the whole nutritious and adequate. Service users have a contract in place and their needs are being met and the overall outcomes, for service users are positive. “One service user commented that the manager and his family and the staff are all very caring towards me and are aware of my needs. Recently I attended my grandsons wedding and got lots of support and extra help and reassurance from everyone in the days leading up to the event. As a result of the support I received I had a lovely day out with my family everyone is very kind. I enjoy having my hair done each week and love to have my nails done too” Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 6 Another says “ my family are very please with the care and support I receive here. I am less anxious, and happy and settled. I always look clean and well dressed. The staff communicate very well with my family” “Mum is safe and happy, when staff to talk to mum her face immediately lights up and she smiles that’s a good sign she is happy to us, mum knows what she likes and doesn’t like and her face would tell us if she was unhappy” We can visit mum anytime and we are always made welcome and well informed” “We are very happy with his care and the home and wouldn’t want our relative to be anywhere else” What has improved since the last inspection? What they could do better: The providers are still not currently providing clear information materials of what the home offers and this must be rectified to establish the foundation for setting out its aims and objectives, range of facilities and for fully informing prospective service users/representatives to enable choice about whether the home is suitable and able to meet the individual’s particular needs. There were minor areas to address in relation to financial procedures at the previous inspection, which were not assessed at this inspection. The inspector advised that there was an obvious lack of visual cues for service users with dementia and suggested that the care manager look at implementing pictures and symbols throughout the home. There were some areas in relation to detail in care plans and healthcare checks, which were not fully satisfactory. The system for medication administration requires further review to ensure it is safe. Several policies and procedures required further development The policies for dealing with service users who are dying examined in the home require consolidation. There are some areas, which require attention temporarily until the ground floor bathroom is fully re-furbished. The health and safety of service users may be compromised regarding evidence once again of a breach in practice for COSHH [Control of substances hazardous to Health] and in relation to other hazards identified around the pantry store and laundry room and fire safety. Please contact the provider for advice of actions taken in response to this Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 7 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 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 the following standard(s): 1,2, 3,5 The providers are still not currently providing clear information materials of what the home offers and this must be rectified to establish the foundation for setting out its aims and objectives, range of facilities and for fully informing prospective service users/representatives to enable choice about whether the home is suitable and able to meet the individual’s particular needs. Service users have a contract in place their needs are being met and the overall outcome for service users is positive. Service users are able to visit the home prior to admission and have their needs fully assessed prior to admission. The home does not provide an intermediate care service Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 10 EVIDENCE: The statement of purpose and service user guide in the home were inspected. The Statement of Purpose and service user guide were found to still have shortfalls the regulations and NMS. The manager was advised to revisit the document and provide CSCI with a revised copy urgently. The Registered Person must comply with Schedule 1 and Schedule 5 of the Regulations, which clearly indicate the content, needed for to meet the regulation within them. Service users and their relatives confirmed that they received good information when looking around and on moving in to the home, that the procedure was not rushed and made to feel welcome and all questions answered. The terms and conditions document has been prepared and there was evidence that this is now in use. The document examined was comprehensive. All service users should be issued with the terms and conditions and a copy held on their individual file. It was observed during the inspection that a change of rooms that was had involved the relative and service user in the decision of the room change had been fully documented. Four service user’s files examined had relevant assessment detail, and these had been reviewed to reflect the service users changing needs. Attention to detail is needed to ensure that the information is relevant and fully up to date. The provider is now using assessment tools for nutrition and tissue viability. The service users social needs, likes and preferences were also covered but further development of the service users social and leisure needs and equality and diversity issues and individuals capacity for consent should be expanded upon. The assessment however was dated when completed and was endorsed by the service user or representative. All service users spoken with reported that they were happy with the care provided and service users were observed to be relaxed and comfortable throughout the inspection. The Providers have many years experience in care provision and state that they have cared for service users with dementia type illness in their other care home, however Beech Court is more specialised provision and the provider is developing staff to meet the varied needs of the service users. Staff members have undertaken training in dementia care and activities for people with dementia. The inspector advised that there was an obvious lack of visual cues for service users with dementia and suggested that the care manager look at implementing visual and colour cues, tactile surfaces and symbols throughout the home to aid with orientation.. Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 11 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 Specific care plans generally direct staff of how they should meet service users needs. Service users’ health care needs and personal needs are being fully addressed and met. The system in place for the management of medicines is satisfactory but should be reviewed to ensure a fully safe system. Service users are treated with respect and their privacy upheld. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service EVIDENCE: Four care plan files were examined and there was evidence that generally clear direction as to how to meet the needs of service users is detailed and is in the form of identified risks and care planning. There were, however some areas which were not fully satisfactory and the manager was advised as to the following: A history of falls sheet for one service user indicated no falls since 2005, yet the accident record detailed this to be inaccurate. Blood test results were not always followed up. Some care plans and risk assessments had not been reviewed on a monthly basis. There was no care plans in place, which Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 12 addressed how the social and recreational needs of service users will be met. One service users whose nutritional assessment indicated cause for concern had not been reviewed since September 2005 and there was no care plan in place for this either. Weight records were in pounds and ounces and kilograms, which made it difficult to track. One service user who was presenting aggressive outbursts had no care plan in place to instruct staff how to manager this. Body maps should be used to indicate where pressure areas are sited and clearer recording of pressure areas, care needs and details of what equipment is provided for pressure relief is needed. Daily diary notes were examined and were generally satisfactory. Service users and a relative spoken with were generally aware of their care plans. There were signed agreements within care plans also. A relative said that as her relative’s needs and care increases, the support needs adjusting accordingly and this happens, “we are involved in our family member’s care plan and staff inform us of any changes in her care” Staff are only too willing to listen to us and help they are very approachable” There were good records kept regarding outside professional input such as GP and district nurse visits. Observations made of staff, the providers and care manager interacting with service users provided evidence of mutual respect and kindness. Copies of accident records were examined. The providers had installed a new medication system, which was examined at the previous inspection and the pharmacist inspection. Policies and procedures for medicines management are in place. The home is registered with a local pharmacy and a blister pack system is in use. Observation of administration of medication in the dining room alerted the inspector that consideration of a lockable box is needed. On the day of the inspection there were only two care staff on duty and medication is dispensed from the dining room, leaving medication unattended if the other staff member is called away to attend service users. Staff members who are authorised to administer medication have attended medicines management training and the audit system is to include competency assessments. There were only two medication pots available, it was reported that some new ones were on order, care should be taken to ensure there are adequate stocks of medication pots for all service users’ medication. The medication charts examined all appeared satisfactory. Service users spoken with confirmed that staff were respectful and polite. Staff were observed respecting service users privacy and knocked before entering their rooms. There are policies and procedures in place for dealing with dying and death, however these were noted to be duplicated at a previous inspection and need consolidating into one policy. The home’s policy for Physical Care of the dying which states care charts will be implemented to record nutritional intake, turns, oral care etc. Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 13 Service users’ files contain the wishes of individuals at the end of life. Although spiritual needs are covered within the assessment documentation. Service users commented as follows: “ The staff are always kind and helpful” “Staff are very patient and are always about” “They are not afraid to get the doctor in if I feel unwell, always give the correct medication when I need It” I am taken to the doctors when I need to or the doctor calls to see me. I receive my medication appropriately. Recently I broke my hip an ambulance was called and the manager accompanied me to hospital. The care manager visited me bought all I needed and bought me flowers and a card I could not be cared for or supported any better. Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 14 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): 12,13,14,15 The provision of stimulation and activities in the home is being further developed. Trips out have been successful. Service users maintain contact with family/friends/representatives and the local community as they wish. The meals provided are overall on the whole nutritious and adequate. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service EVIDENCE: There was evidence of activities provision in the home, service users made comments to enjoyable trips and walking out. A record book for activities is in place. Resident meeting minutes addressed where service users wished to visit. The social and recreational needs of service users should be obtained fully and included as a care plan for each person. A service users said “ It is difficult for me to take part in activities but the staff encourage me and support me - there is often entertainment from outside the home which I enjoy. I usually take part in trips outside of the home with lots of support” A relative said” I have been involved in activities that take place outside of the home i.e. to the safari park, concert. I always enjoy joining in and we are Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 15 made to feel that we are welcome to join in concerts arranged at the home and can always turn up at any time” Service users were observed to move freely around the home. Rooms were observed to be personalised and contain service users’ own personal possessions that had been brought with them to the home. Service users confirmed they went to bed when they chose to. Information on advocacy is available and there was a notice on the notice board informing visitors that service users will be asked if they wish to receive visitors and if not this will be respected. A `service user commented that she is pleased that the home had an available place for her and that her husband is also looked after when he visits” “ I can get up in the morning and go to bed at night when I want to, I have a nap in the afternoon and even have breakfast in bed. I have support with all activities of daily living in a dignified way. If I don’t want to sit in the dining room for my meals I can sit in the quiet room and if I want to go out for a little walk the staff will accompany me. If I don’t want a bath or hair wash they accept this and attend my hygiene accordingly” The menu was set for a week, evidence was handwritten and the cook informed service users of the daily meal options on the menu board in the dining room and detailed two options, however service users reported that they did not have a choice or knew what was on offer for lunch. There was no pictorial format of the menu, so service users who cannot read would not benefit from the menu information on the notice board. The cook keeps a record book of what has been served but this did not provide a record of service users choosing the options on offer. Staff commenced a record on the day of the inspection. Staff were observed to ask service users if they wanted porridge or cornflakes at breakfast. Visiting relatives were not aware about meal choices being usually offered. The menu board offered fish and chips, potatoes or fish cakes on the day of the inspection. Service users were observed to be relaxed and happy at mealtimes. A relative commented, “because of mother’s dementia her appetite can be very variable. However Beech Court do their utmost to provide some food she will eat on that day” A service user stated Food is well cooked and fresh” Another confirmed there is a choice of meals, which are cooked on the premises and includes a soft diet for those who need one. “I have gradually gained weight during the fifteen months I have been at Beech Court” Another relative said” there always seems to be a good menu, my relative does not have a big appetite but never goes hungry, in fact she has put on weight since being a resident which is good” Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 16 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): 16,18 Service users and relatives were clear about making a complaint should they need to. There were no recorded complaints made to the home since the last inspection. CSCI have not received any complaints about the home. The provider is more aware of local adult protection protocols. Several policies and procedures required further development. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service EVIDENCE: The complaints procedure is issued with the service user guide and was displayed / cited close to the visitor’s book. It meets the standard and informs the reader that all complaints will be responded to within 28 days. Service users and relatives all confirmed they would make a complaint through staff if they were unhappy about anything. One service user said, “any of the staff can be spoken to in relation to making a complaint. If the manager is not in you can be sure they will pass information on” Other statements were made as follows: “I have never had to complain in over two years” “I can speak with the care staff or take myself to the office to sit with he manager they take their time to understand what I want to say” Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 17 “Mum doesn’t like too many people or noise around her she knows she can go to the office and just sit there whenever she wants” I just tell someone and my family know how to make a complaint there has never been any need to make one” A policy for adult protection and whistle blowing is in place and needs further development, as it is brief. Three service users reported that they felt safe in the home. Training is provided in Safeguarding Adults. There have been no issues since the last inspection. At a previous inspection the following were identified, however the inspector did not check these at this visit and will carry this task over to the next visit. There is a policy for restraint, this needs to be expanded to include use of bedrails, lap belts etc. The confidentiality policy needs to address when information must be passed on/reported and that the service user or other individual making a disclosure is informed of this. The policy for staff benefiting from wills or accepting gifts should inform staff that this is not acceptable practice rather than just recommend they do not accept gifts etc. The registered provider should review all the policies as identified at the last three inspections and send the revised copies to CSCI. Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 18 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): 19.24.26 Service users live in a generally clean, well - maintained environment that is currently being re-furbished to improve the quality of facilities for service users. There are accessible, safe indoor and outdoor communal areas, where service users are free to wander. Bedrooms meet standards and are personalised. There are some areas, which require attention temporarily until the ground floor bathroom is fully re-furbished and some issues that may compromise service users health and safety. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The new provider has commenced a programme of refurbishment of the home and is keen to improve the standard of accommodation and facilities of the home. New chairs and carpets have already been purchased to improve the comfort and appearance of the home for service users. The small lounge has been fully refurbished and creates a homely and quiet sitting area, which Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 19 overlooks extensive gardens. The garden area is pleasant and spacious and this is to be made more accessible for service users and extended to provide safe and secure outdoor space for service users who wish to spend time in the garden. The provider reported that there are plans to extend the car park and build a new patio area, which has been started. The kitchen has been re-furbished. Call alarms and grab rails are provided throughout. The bath on the ground floor has a patch of missing enamel caused by the bath hoist and the rail around the toilet should be painted and this should be addressed. The provider/manager reported at the last inspection that the bathroom was to be refurbished fully around Christmas time. This is still to be undertaken. Service users’ bedrooms examined were clean, personalised and equipped to meet service users needs. Lockable facilities were seen in the bedrooms examined and files addressed whether service users have been offered keys to their rooms or whether ‘risk assessed’, as not able. The water system has been problematic for the new owner, which is being assessed currently by plumbing contractors and appears to be now satisfactory. Temperature of water outlets, are taken but it is recommended that, all rooms be tested monthly. Records of these temperatures are kept with any action taken. The temperature of the home was appropriate and lighting sufficient and domestic in type. An upstairs bathroom is currently being used as a storeroom and should be locked out of use. A grab rail around the toilet on the first floor needs re-painting. There was some damp problems still identified in the pantry and also in the ground floor bathroom store cupboard, this will hopefully be remedied as part of the refurbishment plans. Care should be taken in relation to food storage on the disused chest freezer, which is rusty. There was also some spillage of food products on the potato bin lid, which had not been cleaned. Flour and powdered products should be stored in sealable containers. The pantry floor felt slippery with residue and in need of a clean as was the light switch. The pantry door was left unsecured. Several bottles of alcohol were stored in the pantry and this also posed a risk should service users wander in there. The laundry area/systems appears adequate to meet the home’s needs, however this is being used as a smoke room for staff also. Metal bins were not provided and several cigarette nubs were seen in a plastic dustbin with paper towels and the door wedged open. The registered provider must consult with the fire officer in relation to ensuring fire precautions are adequate in relation to permitting smoking in this area. Cleaning products were found stored in an unlocked cupboard in the ground floor bathroom, they were stored amongst several tubs of various creams which most were unnamed and partly used. This indicated inappropriate storage and communal use of creams. The registered provider reported that Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 20 the creams would be discarded at once and staff would be reminded about COSHH regulations once again. The home was found to be otherwise clean and free from mal odour. Gloves and aprons were provided around the home. [See standard 38] Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 21 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 The numbers and skill mix of staff meets Service users’ needs. Staff are trained and competent to do their jobs. Recruitment procedures were satisfactory. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service EVIDENCE: Staffing rotas demonstrated sufficient staffing numbers. The registered provider needs to address the situation in relation to medication administration as identified when only two care staff are on. Generally three care staff are provided on daytime and evening shifts and two waking staff on at night. Laundry, domestic, handyperson and catering hours appear sufficient. Of a general rule the provider has estimated that over a normal week the home is staffed 38 above the minimum staffing levels. Dependency levels need to be considered within this estimation. The home has employed both agency staff and used staff from the provider’s sister home to ensure staff cover when staff shortages have occurred. A good level of training is provided, evidence of an annual staff training plan was seen and some evidence was in the personal files seen. Staff are undertaking NVQs. Most staff hold or have almost completed NVQ training of at least level 2. Induction to skills for work is provided. A sample of staff files was examined, including staff employed by the provider’s sister home. The registered provider/manager of Beech Court was happy for records to be examined, however the inspector experienced some Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 22 difficulty with the Registered Provider’s manager of the other home not being initially compliant with the regulations. Where staff work at more than one of the provider’s homes, a copy of their personal record must be held at each home. The staff files were satisfactory in relation to the requirements of schedule 2 and 4. Supervision records were not evident in the files for staff mainly employed at Beech court. The Registered Provider is advised to refer to CSCI guidance policy for the storage and retention of records and Schedule 4 of the amended Regulations. Records evidenced a good level of training. Service users comments as follows: “ There are staff employed to ensure the home is fresh and clean also a laundry lady who ensures my clothes are washed and ironed and returned to my bedroom” Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 23 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): 31,33,35,36,37,38 The provider/manager has completed NVQ 4 and has updated training on a regular basis. There was some initial difficulties experienced at the inspection regarding accessing some records which involved the registered managers partner provider. Quality monitoring systems are in place and records kept secure. There were minor areas to address in relation to financial procedures at the previous inspection, which were not assessed at this inspection. The health and safety of service users may be compromised regarding evidence of a breach in practice for COSHH [Control of substances hazardous to Health] and fire safety issues once again. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service.” Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager is also the registered provider, who has many years experience in the caring profession and in running and managing a care home. He has a NVQ 4 and there was evidence that the registered manager keeps up to date with other training. [See standard 29-re access to records issue] Relatives stated that the providers are very caring and service user focused people. Evidence was seen to support that staff meetings are held. Quality monitoring systems are being developed. Because the service users had recently completed questionnaires for CSCI the manager had delayed distributing their own surveys. A quality consultative committee is being organised. A sample of service users’ financial records was examined at a previous inspection and found to be satisfactory apart from not always having two signatures for transactions. It is recommended that procedures for safeguarding staff and service users are amended to include a checking system for when staff do any shopping for service users. This standard was not reassessed at this inspection due to time constraints and therefore recommendations carried over to the next inspection. Evidence in relation to staff supervision was minimal and needs to be improved. Records are stored safely. Observations made at the inspection were that staff practices were not always appropriate of promoting health and safety. These issues are highlighted through the report. Breach of COSHH regulations is outstanding. Further noncompliance may result in enforcement action being taken. Staff were however observed to wear protective clothing for attending to service users personal care and when serving food. Health and safety policies were in place. The provision of training is good and the servicing and maintenance of equipment seen to be satisfactory. Magnetic door closures, which release when the alarm is triggered, have been fitted to enable doors to be held open during the day. A fire risk assessment was not produced for inspection. Evidence of these needs to be provided. The Environmental Health Officer visited on 28/11/05. Some issues were noted in relation to the damp in the storeroom, lid on the chest freezer, diffusers to be fitted to fluorescent strips and advice was provided for cooking of eggs. Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 25 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 2 3 3 X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 3 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 2 2 X X X X 3 X 2 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 2 2 3 2 Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 26 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 OP1 Regulation 4 Requirement Timescale for action 18/09/06 2. OP1 3. 4 OP7 OP19 OP26 OP38 The Statement of Purpose must be completed as specified in Schedule 1 of the RegulationsOUTSTANDING previous timescale 22/12/05 NOT MET 5 A Service user Guide must be 18/09/06 produced to meet Regulation 5 requirements and to be issued to prospective and existing service users OUTSTANDING previous timescale 22/12/05 NOT MET 14,15 Ensure that care plans are 18/09/06 implemented for all service users in line with their assessed needs 13, 16, 23 (4) The registered person shall 18/09/06 ensure that— (a) all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety; (b) any activities in which service users participate are so far as reasonably practicable free from avoidable risks; and (c) unnecessary risks to the health or safety of service users are identified and so far as possible eliminated, Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 27 5 OP19 OP38 13,23 The registered provider must 18/10/06 ensure that staff follows COSHH [Control of substances hazardous to health] regulations at all times. OUTSTANDING previous timescale 22/10/05 NOT MET 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. 10 Refer to Standard OP4 OP8 OP8 OP9 OP9 OP11 OP15 OP21 OP22 OP36 Good Practice Recommendations Provide visual cues around the home for assistance to service users with dementia Ensure that blood tests are followed up Weight records should be completed in a consistent reading manner Ensure there are enough medication pots for all service users medication. Review the medication administration practice in relation to when only two staff is on duty. Consolidate and review the policies as identified within the report and send evidence of this to CSCI Re-write the menus to include various options of meal types over a four week cycle and record the options taken If the unused bathroom is to be used as a store, this should be closed off Attend to the worn enamel patch on the bath and on the rails around toilets Ensure staff are regularly supervised and records are up to date Beech Court DS0000062132.V296711.R01.S.doc Version 5.2 Page 28 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. 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