Inspection on 30/01/08 for Beech Dene Residential Care Home

This inspection was carried out on 30th January 2008.

CSCI found this care home to be providing an Excellent service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beech Dene Residential Care Home 29/11/06

Beech Dene Residential Care Home 11/01/06

Beech Dene Residential Care Home 28/09/05

Beech Dene Residential Care Home 24/02/05

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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

Inspirations

Westmead

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

CARE HOMES FOR OLDER PEOPLE Beech Dene Residential Care Home Westwood Road Leek Staffordshire ST13 8DL Lead Inspector Linda Clowes Unannounced Inspection 30th January 2008 08:30 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 Beech Dene Residential Care Home DS0000059648.V354300.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 Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Dene Residential Care Home Address Westwood Road Leek Staffordshire ST13 8DL 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) 02476 470465 Mr Simon Badland Mr Anastasis Kayiatou Joanne Caroline Boyle Care Home 35 Category(ies) of Dementia - over 65 years of age (8), Old age, registration, with number not falling within any other category (35), of places Physical disability over 65 years of age (3) Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide personal care to service users of both sexes whose primary care needs on admission to the home are within the following categories: Old Age not falling within any other category (OP) 35 Physical Disability over 65 years of age (PD)(E) 3 Dementia over 65 years of age (DE)(E) 8 The maximum number of service users to be accommodated is 35 2. Date of last inspection 29th November 2006 Brief Description of the Service: Beech Dene is a large, semi-detached property set in mature gardens, in close proximity to the market town of Leek. The extended part of the home is two storeys but the original building has three floors and a large basement, which is used as the laundry room. The CSCI has approved a recent extension/alteration to the property that has provided six single en-suite bedrooms and an additional bath/shower room. The home is currently registered for 35 which includes the option of a shared bedroom where this is requested (e.g. for a married couple). This room also has the flexibility of being used as a single. Care needs vary, ranging from dementia care to residents who experience physical incapacities including, visual and hearing impairment. The home provides a comfortable and homely environment with spacious communal areas, providing lots of natural light and views of the front and rear gardens. In addition, there is also a designated smoking room. There are large, well-kept gardens to the front and rear of the property that have adequate seating. There are plans to improve the rear garden, creating a safe area with screening. In fine weather many residents prefer sitting at the front of Beech Dene as they can observe passers-by and this involves them in the daily activities of the local community. The front of the property is safe and secure, provides adequate parking space, and is monitored with CCTV cameras. Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is 1 star. This means that the people who use this service experience excellent quality outcomes. This was a key unannounced inspection carried out by one inspector and took place over 6.5 hours. The inspection was carried out under the Care Standards Act 2000, the Care Homes Regulations 2001 and the National Minimum Standards for Care Homes for Older People. All of the core standards have been assessed during this visit. Statistical information regarding the service has been provided by the manager in the Annual Quality Assurance Assessment (AQAA). The manager was present for the inspection and full feedback was given throughout the day. The home had a Statement of Purpose and Service Users Guide that provided services users with information so that they could choose whether the home was suitable for them. The documents had been reviewed and updated during 2007 when there had been an application for CSCI for a major variation to the home and a new Certificate of Registration was issued on 31st May 2007. This inspection identified through direct discussion with service users and visitors and feedback from service users, relatives and healthcare professionals that a very satisfactory service was provided by Beech Dene Residential Home. Without exception feedback from all who took part in this inspection was that the home was well managed and had an effective, sensitive and caring staff team. Three requirements and four recommendations have been made as part of this inspection report. What the service does well: Beech Dene provides an attractive and homely environment with a wide choice of communal areas where residents could spend their time. Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 6 The home had a friendly and inclusive atmosphere that was welcoming to service users and visitors. The home was well maintained, clean, homely, warm and cosy. There were many positive comments regarding the quality of the catering. Residents and relatives were complimentary regarding the standard of personal care provided. Staff training was given high priority. What has improved since the last inspection? What they could do better: A new fire risk assessment of the building should be completed to include the six new bedrooms and one new bath/shower room. Individual fire risk assessments should be completed in respect of all residents in the home. Risk assessments should be carried out on windows to ensure security for residents and to prevent intruders into the building. Where there are concerns identified, window restrictors should be fitted. Recommendations from service users and relatives as part of this inspection were for the introduction of a meaningful daytime activities programme that took into account individual interests and capabilities. Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Beech Dene Residential Care Home DS0000059648.V354300.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 Dene Residential Care Home DS0000059648.V354300.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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective residents receive detailed information about the home to enable an informed choice to be made about the suitability of the home for them. Each resident has a pre-admission assessment and a residency contract and were thereby assured before moving into the home that their assessed needs could be met. No intermediate care took place at Beech Dene and, therefore, Standard 6 was not inspected. EVIDENCE: No requirements were made in this outcome area in the last inspection report. A new application for registration had been received by CSCI in early 2007 for major refurbishment to the premises including six new bedrooms with en suites and a new bath/shower room. The application was approved by the commission and a new Registration Certificate dated 31 May 2007 was issued to the home. Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 10 The Statement of Purpose and Service User Guide had been reviewed and updated to reflect the change of ownership to Oldfield Residential Care Limited and the increased numbers that may be accommodated by the home. The Service User Guide included details regarding the provider and manager, qualifications of staff, accepted age range, location, religious needs, visiting, entertainment, assessment details, sample menus, a list of policy and procedures used within the home. The manager/deputy undertake pre-admission assessments. Admissions to the home only take place if the service is confident staff have the skills and ability to meet the prospective residents assessed needs. There were thorough assessment procedures in place for those service users who were publicly funded as well as those who were privately funded. A random sample of three service user files was undertaken to confirm admission and assessment procedures. The service had received information regarding the multi-agency assessments in respect of all three including one who was privately funded. Terms and Conditions of Residency documents include details regarding confidentiality, medication, smoking, personal safety, personal effects, trial periods, termination and payments, the complaints procedure, fees and the scope of the fees, scope of the service (what is and is not included), philosophy of the home, privacy and dignity. Residents were notified by letter of any changes to this contract and a number of residents confirmed this to the inspector on this visit. One person who was case tracked was a new resident who had been in the home for just a few days. The inspector spoke with them and they confirmed that managers and care staff were attentive and kindly in supporting them to settle in. Relatives had arranged for the admission to the home as the resident was transferred directly from hospital. People are encouraged to undertake short-stay and trial visits the home prior to permanent admission. Beech Dene Residential Care Home DS0000059648.V354300.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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents receive effective personal and healthcare support. There were comprehensive care records in place that informed care staff in sufficient detail about the care needs of each resident and enabled them to provide a person centred individual service. Medication records and procedures were inspected and found satisfactory. EVIDENCE: No requirements were made in this outcome area in the last inspection report. The records of health and personal care needs were examined for the three people who were selected as part of case tracking. This together with discussions with a high number of residents indicated that the home fully respects the rights of people in the areas of healthcare and medication. Care staff spoken with were knowledgeable about the care to be delivered to each individual who was part of the case tracking. The medication record of each was inspected and found satisfactory. Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 12 Each of the three service users being case tracked was spoken with and they confirmed that the home looked after their personal and healthcare needs. A high number of other service users were consulted during the day and each confirmed that the staff were “wonderful”, “I couldn’t have better care”, “this is like home”, “this is the next best thing to home”. Four Service users responded to surveys and all four confirmed that they ‘always’ received the care and support they needed; that staff listened and acted on what they said and were ‘always’ available when they needed them. Eight relatives responded to surveys and seven considered that the home ‘always’ met the needs of their relative/friend with one saying that they ‘usually’ did. The following comments were added: *”Staff always ask what my relative needs but sometimes she does not tell them. They will telephone if she needs anything but as I visit on a regular basis it is not necessary”. *”(My) Relative is very happy at Beech Dene so we are happy. (I) visit twice weekly but contact never instigated from the home. (I) am always kept up to date with important issues”. Four healthcare professionals (General Practitioners and Community Nurse) responded to surveys and expressed satisfaction regarding healthcare issues. The following comments were added: *”I have been associated with Beech Dene for many years. I feel over the last few years the quality of communication and the understanding of the medical needs of the clients (as opposed to social needs) has improved enormously”. *”Friendly home; always accompanied when we visit patients to do procedures; (they) act on any advice we give”. The home uses a Standex system of individual care planning. Information therein was comprehensive with evidence of regular reviews of care needs and risk assessments. A record of all healthcare issues was maintained that included visits by general practitioners and other healthcare professionals. A daily record was maintained of personal care provided and significant events. Residents spoken with spoke highly of the home’s response to any health issues that may occur with each confirming that at the least concern a GP was consulted or asked to visit. One relative who visited the home daily spoke of the excellent care provided to their mother who had been bedfast for some time, stating “I cannot speak Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 13 highly enough about the dedication of the staff and the excellent care provided for my mother”. One service user who had lived in the home for some five years said that their health needs had always been addressed promptly. Relatives who responded to surveys were satisfied and added the following comments: *”The home treats people with respect”. *”Medical treatment has been excellent”. *”My mother’s care needs are always met to a very high standard. The Care Team always inform the family immediately if there is any issue relating to her care and comfort”. *”I am very satisfied with the quality of care at Beech Dene and feel that my mother is looked after to a very high standard in extremely nice surroundings”. *”The care is good. My mum’s needs are met”. *”During a recent occasion when my mother had an illness and was admitted to hospital (on her return) the care home’s staff were superb with her medical and dietary needs which put a great deal of work on to them “. Beech Dene used the Nomad Monitored Dosage System of Medication. Managers and Senior care staff were responsible for the administration of medication, although other staff in the home had attained the NCFE Intermediate Certificate in Safe Handling of Medicines. Medicines were appropriately stored. Medication administration records, including controlled drugs records were inspected and found satisfactory. The inspector had extensive discussions with residents, care staff, ancillary staff and two visitors that confirmed high standards of care provision in the home. Observations on the day confirmed that the home fully respects the rights of the people who use the service in respect of healthcare and medication. Beech Dene Residential Care Home DS0000059648.V354300.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The daily routines at Beech Dene are flexible and residents are encouraged to maintain family links. Choice is promoted across many areas of daily life and an excellent standard of catering is provided. Staffing issues have affected the home’s ability to provide meaningful daytime activities both in the home and in the community that should provide stimulation and interest.. EVIDENCE: No requirements were made in this outcome area in the last inspection report. People who use the service have the opportunity to develop and maintain important personal and family relationships. The staff practices promote individual rights and choice but also consider the protection of individuals in supporting them to make informed choices. Care records identified individual lifestyles and goals. Risk assessments had been carried out on all activities taking into account the need to promote independent living skills but also the need to consider protection of individuals. An inspection of menus and discussions with cook confirmed a varied menu with balanced nutritious meals being served. Without exception residents were Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 15 complimentary about the quality and quantity of food served in the home. Each person spoken with said they looked forward to the meals and confirmed that they had a wide choice of good quality food throughout the day. Meals were served in pleasant surroundings. The dining room and adjacent conservatory accommodated dining tables which were attractively laid and which provided a relaxing ambience in which to meet with fellow residents at mealtimes. There was sufficient seating in the dining areas to accommodate the recent increase in numbers of residents. All staff had received training in safe food handling. Residents who responded to surveys expressed satisfaction with the food adding: *”I dislike cheese and potato pie but I am always offered something else”. Relatives comments: *”The home does everything well. The food is great”. Relatives spoken with confirmed that they were always welcomed into the home. Those who returned surveys commented: *”Nice and homely welcome to visitors”. Discussions with the manager and residents identified that current staffing difficulties had had an effect on their ability to provide activities and stimulation for residents. In the Annual Quality Assurance Assessment (AQAA) completed by the manager she identified that “improved staffing levels would improve time spent on leisure with service users. We have asked families to make sure they have sufficient personal allowance entitlement to provide improved individual choice regarding outside activities”. The AQAA document also outlines plans for improvement in the next twelve months to include providing a safe garden and to renovate an existing summerhouse and patio area. It is understood that a recruitment campaign for care workers is currently going ahead and there were plans to change staff shifts. The manager was confident this would provide more capacity for staff to provide greater input into activities for residents. Residents who responded to surveys were generally satisfied with activities in the home with two adding: Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 16 *”I don’t enjoy any activities. I prefer to stay in my room”. *”I don’t always join in. I can’t see too well. I enjoy my memories…” Comments made in surveys include: “More stimulation for some of the residents is needed”. “Although a lot of the residents are elderly they do need more motivation and activity which I do understand is easier said than done. Simple exercise… would benefit all. Also things like drawing or making simple cards or decorations would help”. *”The home can improve by having more activities”. It is important that the home provides stimulus for all residents to suit their individual abilities and inclinations. The last inspection report made recommendations that the home should make provision for residents who are visually impaired to access audio books/newspapers from the library and for individual care planning to include opportunities for outings to local places of interests for those residents who wish to make such trips. As a part of this inspection report a recommendation is made that the home should introduce a realistic programme of meaningful daytime activities to provide choice according to residents’ interests and capabilities. (Recommendation 1) Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service Beech Dene’s complaints procedure was outlined in the Service Users Guide/Contract and issued to all service users prior to admission into the home. The Complaints Procedure was also prominently displayed in the home. Staff had received training to ensure that residents were protected from abuse. EVIDENCE: The home’s complaints procedure is outlined in the Service User Guide/Contract. The complaints procedure was also prominently displayed in the entrance hall. Service users spoken with on the day said they felt confident that any concerns they raised with the care staff or manager would be addressed without delay. The four service users who responded to surveys confirmed that they knew who to speak to if they were not happy and that they knew how to make a complaint. Relatives spoken with had not raised complaints but said they would have no hesitation doing so. The majority of relatives who responded to surveys knew how to make a complaint. Several comments were added as follows: Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 18 *”I complain to the office if I do not agree to anything but everything is always sorted out amicably. They have always acted promptly. I rarely have cause to complain”. *”I wouldn’t hesitate to complain but in my own way. I am not aware of complaint procedure/protocol”. *”The only concerns we have had have been very minor ones which have always been resolved satisfactorily”. The manager confirmed that any minor grumbles were dealt with immediately in line with the home’s quality assurance procedures. The AQAA document identifies that the home had received no complaints in the last twelve months, neither had there been any safeguarding referrals. The CSCI had not received any complaints about Beech Dene since the last inspection. There was evidence that staff had undertaken training in the Protection of Vulnerable Adults from Abuse and discussions with a random sample of care staff confirmed that this had taken place. There were policies and procedures in place to protect residents. All staff working in the home had been checked via the Criminal Records Bureau Enhanced Disclosure system (Police Checks) and the Protection of Vulnerable Adults from Abuse Register (POVA) prior to deployment. Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,22,23,24,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Beech Dene provides an environment that is appropriate to the lifestyle and needs of residents and is homely, clean, safe and comfortable. The home is well maintained and hygienic throughout. EVIDENCE: No requirements were made in this outcome area in the last inspection report A tour of the building was undertaken including all communal areas and a sample of bedrooms, bathrooms and toilets. The home was clean, pleasant and hygienic throughout. Residents commented that the home was always clean and fresh. Those who returned surveys confirmed that the home was ‘always’ clean and fresh. Aids to daily living to promote independence were in place and the manager confirmed that as requested by CSCI during the recent alteration to the home’s Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 20 registration she had sought advice from the occupational therapist regarding aids in the new bedrooms and bathroom areas. There were several communal areas, all of which were being well used by residents. Three, including the dining room, are part conservatory which affords a good standard of natural light and views to the front and rear gardens. Last year’s inspection report records that there were plans to improve the rear garden during summer 2007. However, this has not yet taken place and the AQAA document outlines plans for improvement in the next twelve months as follows: “We intend to make a safe garden area at the back of our home for residents to be able to wander safely around it and not come to harm”. The manager confirmed that a Summer Fete would be organised to raise funds for this improvement that would address issues such as the steep steps, the gradient of the ramp and the various levels around these features. A recommendation has been made as part of this report for the home to ensure that the grounds are safe and accessible to service users. (Recommendation 2) Residents who were being case tracked showed the inspector their bedrooms and expressed satisfaction with them. Residents and relatives confirmed that the home was always warm. Radiators had been fitted with radiator covers to promote health and safety. A random sample of the rooms that had recently been converted found that they were suitably proportioned, had en suite facilities and were well decorated and furnished. One resident said that they were very pleased with their bedroom, the only complaint being that it took a long time for hot water to reach their wash hand basin. The inspector checked this and discussed it with the manager. Hot water was, indeed, a long time coming through the pipes but it did eventually. The manager agreed to monitor this situation. It was also noticed that there was no plug in situ and the manager confirmed that she had asked for plugs to be provided – it may mean the fitting of another waste outlet to accommodate plugs. A new sluice had been fitted since the last inspection. Legionella tests were up to date Domestic staff were NVQ trained or working towards this award. It was noticed that the new front entrance to the home was not yet completed. The manager has been asked to write to the CSCI to confirm when this work has been completed and the new entrance is in full use. (Recommendation 3) Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 21 Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs were met by the numbers and skills-mix of staff. However, long-term sickness had put extra pressures on the staff team as they have had to cover extra shifts for some time. Good induction and on-going training provide staff with opportunities to improve practice. Robust recruitment procedures were in place to protect service users. EVIDENCE: There were no requirements made in this outcome area in the last inspection report. Without exception residents who were spoken with on the day and those who returned surveys, together with surveys returned from relatives all confirm that staff are competent, attentive and kindly. Discussions with the manager and care staff identified the difficulties experienced in recent months that covering for long-term sickness had placed on the staff team. It is understood that there are 9 full time care, including the manager and 11 part time staff in the care team who are supported by 8 other ancillary staff. In view of this situation it is remarkable that in the last 3 months only 6 care shifts have been covered by agency staff. The manager has also worked hands-on to cover shifts and this has, as a consequence, had an impact on her management role. Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 23 The manager confirmed that she was presently seeking to employ additional staff, including senior care staff, and to change shift patterns that include moving from the present 12 hour shifts to 7 hour day shifts and 10 hour night shifts. A recommendation was made in the last inspection report that a designated senior should be on duty in respect of night time cover in addition to the three waking night staff. The AQAA document states “each shift is charged with senior care staff “. It is understood that the present exercise to increase staffing will further increase the numbers of senior care staffing. Of the 19 care staff, 11 had attained National Vocational Qualification (NVQ) level 2 in care with 3 working towards this award. A random sample of 3 care staff files was inspected and robust recruitment procedures were identified that included the taking up of references and police and POVA First checks. Induction training had been carried out and all mandatory training. The three care staff were interviewed in private and confirmed that they received mandatory training and had access to on-going training such as safe handling of medication, dementia awareness, abuse awareness. Staff confirmed that they received supervision and that they were well supported by the management of the home. Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 24 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. There was an atmosphere of openness and respect in which residents and their advocates and staff felt valued and that their opinions matter. EVIDENCE: There were no requirements in this outcome area in the last inspection report. The Registered Manager, Ms Joanne Boyle had been involved with the home since 1986. At one time she was part owner and was approved as Registered Manager by the Commission in 2001. She has continued in this role following the recent sale of the home to Oldfields Residential Care Limited. Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 25 Following the recent sale Ms Boyle has benefited from visiting other care homes owned by Oldfields Residential Care Limited and is eager to introduce good practice she has identified in other homes in the group. Ms Boyle worked hard to ensure that the home had a relaxed , friendly and inclusive atmosphere. Residents and staff confirmed that the manager was approachable and supportive. There was evidence of staff supervision and staff spoken with confirmed that they received supervision. There was a relatively stable workforce with only 6 care staff leaving in the past twelve months. Records in the home were stored securely to comply with Data Protection Act 1998. The home encourages families and advocates to take responsibility for residents finances and only holds small amounts of money to cover for example, weekly hairdressing. Appropriate Insurance was in place to protect the business. The AQAA document identifies that feedback is actively sought from service users and relatives. However, information regarding any quality audits was not provided by the home as part of this inspection. During the tour of the home, it was noticed that window restrictors were not fixed on windows. The manager has been asked to carry out risk assessments on both ground floor and first floor windows to assess risks to residents and where concerns are identified window restrictors must be fitted. This exercise must take into account the risks to people with dementia care needs, or mental health needs and must also ensure that windows are secure and protected from external intruders. (Requirement 1) During an examination of fire records it was noted that the Building Fire Risk Assessment needed to be reviewed to include the new bedrooms. It was also noted that Individual Fire Risk Assessments should be carried out that ensure the safe evacuation of all persons in the home in the case of fire. It is important that this assessment includes instructions to staff taking account of different times of the day and, for example, any health issues such as persons with dementia or the impact of medication. Requirements have been made as part of this report in relation to these issues. (Requirements 2 & 3) At the recent application for a major variation, the proprietor was asked to confirm to the CSCI that he has applied for the company to be registered in respect of Beech Dene. As the manager was not sure that this request had Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 26 been complied with a recommendation has been made as part of this report that the proprietor write to the Regional Registration Team at the CSCI, 77 Paradise Circus, Queensway, Birmingham, B1 2DT to confirm this point. (Recommendation 4) Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 27 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 3 3 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 4 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 3 3 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 3 3 X 3 3 x 2 Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 28 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 OP38 Regulation 13(4)(a) Requirement Risk assessment procedures should be carried out on all windows in the home to ensure the safety of residents, particularly bearing in mind that some have dementia car needs, and where concerns are identified window restrictors must be fitted. This exercise should also look at windows that may be vulnerable to external intruders. This will provide appropriate protection for people who use the service. A full fire risk assessment of the building should be carried out following the recent extension of the home. This will ensure the health and safety of people who use the service. An individual fire risk assessment should be undertaken of each resident to ensure their safe evacuation in the event of fire. Timescale for action 31/03/08 2 OP38 23(4)(c) (iii) 31/03/08 3 OP38 23(4)(c) (iii) 31/03/08 Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 29 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 OP12 Good Practice Recommendations An Activities Programme should be introduced that provides residents with meaningful daytime activities of their choice and capabilities both within and outside the home. This will provide stimulation and enjoyment for those residents who wish to undertake leisure activities and maintain community links. It is recommended that the home ensure that the grounds and particularly the rear garden are safe and accessible to service users. The will enable people who use the service to enjoy safe grounds which are suitable for, and safe for their use. It is recommended that the manager confirms in writing to the CSCI when the new entrance to the home is completed and brought into full use. To comply with the request from the Regional Registration Team as part of the recent registration application for major variation, that clarification be given regarding the status of Beech Dene in the group of companies that comprise Oldfields Residential Care Limited, the proprietor should write to the CSCI to confirm that the company (Oldfields Residential Care Limited) is registered in respect of Beech Dene. 2 OP19 3 4 OP19 OP31 Beech Dene Residential Care Home DS0000059648.V354300.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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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