Inspection on 17/01/07 for Beech Haven

This inspection was carried out on 17th January 2007.

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 Haven 09/05/07

Beech Haven 29/08/06

Beech Haven 15/11/05

Beech Haven 10/05/05

Beech Haven 17/08/04

Beech Haven 26/04/04

Beech Haven 08/09/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Beech Haven 15-19 Gordon Road Ealing London W5 2AD Lead Inspector Ms Jane Collisson Key Unannounced Inspection 10:45a 17th January 2007 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 Haven DS0000027723.V322390.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 Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beech Haven Address 15-19 Gordon Road Ealing London W5 2AD 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) 0208 991 0658 0208 991 0658 beechhaven@myway.com Mrs Phaik Choo Scarman Mr John Scarman Mrs Phaik Choo Scarman Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user with Dementia can be accommodated, as agreed by the Commission for Social Care Inspection, on 19th January 2006. The service user may remain resident until such time when the home is unable to meet the individual service users assessed needs and care plan and for as long as there is no deterioration which affects the well being of other service users. The home must advise CSCI when the service user no longer resides at the home. 29th August 2006 Date of last inspection Brief Description of the Service: Beech Haven is a private care home for thirty older people. It was first registered in 1986 under the Registered Homes Act 1984. The Registered Providers are Mr and Mrs Scarman and Mrs Scarman is the Registered Manager. Currently the home is registered for older people only, including those with physical disabilities. There is one variation to the categories of registration for a service user who has dementia. The home is three large attached houses, in a residential area near to Ealing Broadway. The home has easy access to shopping facilities and local amenities, including places of worship. An underground and main line station, and several bus routes, are close by, and the North Circular Road and A40 are within a few minutes’ drive. The accommodation consists of thirty single bedrooms, which are on three floors. There is a large lounge/dining room that is equipped to comfortably accommodate all of the service users for their meals. The lounge overlooks an attractive enclosed garden to the rear of the home. The main kitchen is off the dining room. There is a small lounge situated at the entrance of the home. The service users use this as a quiet area to see visitors and for review meetings. There are adequate bathroom and toilet facilities on each floor. A passenger lift is provided and there are ramps to access the home and garden. To the front of the home there are parking spaces for several cars. The fees for the home are from £460 to £530 weekly. Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection commenced on the 17th January 2007 between the hours of 10.45am and 4.45pm. The Registered Provider/Manager was present. The other Registered Provider was on a first aid course. As he is responsible for the training and administration, a further visit was made on the 2nd February, from 9.50am, to discuss the outstanding requirements and future plans for the home. The inspection process took a total of twelve hours. There were sixteen service users present on both visits to the home. It was confirmed by the Registered Providers that a number of the service users have diagnosed dementia although the home is not registered for this category. The Registered Providers have not been admitting service users with this diagnosis but have applied to the Commission for Social Care Inspection to change the home’s category of registration to dementia care. The CSCI’s Regional Registration Team was considering this application during the inspection. The majority of the service users were met, and spoken to, during the course of the inspection. Although most were in the lounge/dining area, a small number of service users choose to spend their days in their bedrooms for all or part of the day. During the first visit, one service user went out independently and another was out with family members. Service users had the opportunity to take part in the weekly religious service which had taken place during the morning. During the afternoon of the second visit, a volunteer was supporting a small group of service users to play dominos. Two visitors were met and four questionnaires were returned from relatives or people who visit the home. Two mealtimes were observed during this inspection. Five staff were met and the number of staff on duty was in accordance with the rota. One staff member was available to accompany a service user to a hospital appointment. Records and documentation were examined, including care plans, staff and training files, and maintenance schedules. The samples seen indicate that there is still a need to improve the quality of the information being recorded, although the Registered Providers had started to make some progress with this. Few changes has been made to the environment, although upgrading is still being planned which includes new carpets and armchairs. A new call bell system had just been installed and fire servicing was being carried out on the day of the first visit. At the previous inspection, in August 2006, sixteen requirements were made. The Registered Providers were asked to provide an Improvement Plan following that inspection. They have fulfilled a number of the requirements but six Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 6 remain outstanding and a further eight have been made at this inspection. All are required to be completed within the given timescales. What the service does well: What has improved since the last inspection? What they could do better: Prospective and current service users, and their representatives, would benefit from the revised Statement of Purpose and Service Users Guide being provided to them. In order to show that service users are only admitted when it can be shown that their needs are able to be met, sufficient information must be provided, and recorded, to show that a full assessment has been carried out and consultation has taken place. With the changing needs of the prospective and current service users, the Registered Providers need to demonstrate the home has the capacity, in terms of facilities, staffing, and training, to continue to meet the service users’ needs. The information on the risk assessments was insufficient to evidence that the health and safety of the service users had been taken into account. A more thorough assessment, which is regular reviewed and agreed with the service users and their representatives, needs to be in place. Staff carrying out manual handling risk assessments must have the training and skills to be able to do so, with the information clearly stating how the risks will be minimised, and which equipment is to be used to maximise safety. Better information and recording, regarding the health and welfare of the service users, and how they are being managed, is needed. To gain the relevant information, the involvement of service users, their families and health professionals, should be in evidence, together with agreement on how the needs are managed. An improvement in the medication procedures, together with regular monitoring by the Registered Providers, is necessary to demonstrate good management. The provision of more accessible information would assist the service users with their knowledge of the activities programme and their choice of meals. Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 7 The range of activities, both for groups and individuals, needs to be expanded, following consultation with the service users. Staff would benefit from having training in providing appropriate activities. The Registered Providers need to ensure that all staff have the required core and specialised training to assist them to fulfil their roles and develop their skills. The records indicated that not all of the staff have the required basic training. First aid and food hygiene were among those courses that were outstanding for most of the team. Although some progress is starting to be made, insufficient attention has been given to demonstrating that the quality of care is reviewed regularly and there is a programme of improvements. Consultation with the service users and their representatives is essential to this process. The support of the staff team, through regular supervision sessions and staff meetings, needs to be more structured. This would help to demonstrate that there is sufficient consultation and information-sharing to support them to develop their roles and maintain a high standard of care for the service users. The Registered Providers need to continue with the improvements to the record keeping that have commenced to demonstrate that service users’ needs are being met, and that all of the required health, safety and training documentation is up-to-date. To maximise safety in the home, the provision of an updated fire risk assessment is required to be completed in accordance with the new legislation. 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 Haven DS0000027723.V322390.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 Haven DS0000027723.V322390.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, 3, 4 (NMS 6 is not applicable as there is no Intermediate Care unit) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective and current service users, and their representatives, would benefit from being provided with the updated versions of the Service Users Guide and the Statement of Purpose to support them to understand, and make decisions about, the services and facilities offered by the home. The assessments had insufficient information to demonstrate that all of the needs of the service users could be met by the home. The home’s categories of registration are no longer appropriate for all of the service users living in the home, due to their increased dependency and medical diagnosis. EVIDENCE: The documentation for service users and prospective service users to gain information about the facilities and services offered by the home have been amended and updated. The Registered Providers said that the information could be provided in larger print, if required. There are further small amendments required before the documentation is issued. Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 10 The Service Users Guide now includes a copy of the terms and conditions for the home. In order for service users, and their representatives, to be clear about the services they may have to pay for, the Registered Providers were advised to include additional information, such as having to pay for chiropody when it is not available from the NHS. One of the newer service users was unsure as to whether the Guide had been provided upon admission to the home. Now that the documentation is being revised, it should be reissued to the service users so that they have access to the up-to-date information. The Registered Manager generally undertakes the assessment process of new service users but no written assessment information was seen in one of the files examined. There was insufficient information on the care plans to evidence that the individual needs of the service users had been fully considered or that consultation had taken place. Service users confirmed that they were able to visit the home, prior to admission. The Registered Providers were advised to consult with prospective service users, at such times, as it is a useful opportunity for them to discuss their individual needs and should support them to make a decision about what the home has to offer. The Registered Providers had, prior to this inspection, made an application to the Commission for Social Care Inspection to have the home registered for people with dementia. This has been brought about by the changing needs of the current service users, and those now being referred. The CSCI’s Regional Registration Team was undertaking this assessment during this inspection period. One variation to the category of registration, for a service user with dementia, is already in place. The general practitioner has agreed that several service users have this diagnosis. While the Registered Providers are aware that they may not admit anyone outside of their current categories, they need to make provision for the current service users to have the care and support they require. Applications to vary the category of registration must be made where the needs of the service users can continue to be met. Evidence of the continuing suitability of the environment, levels of staffing, activities and facilities will need to be provided. The Statement of Purpose will need to be amended to reflect the changes if the applications are granted. The home has no Intermediate Care unit so this National Minimum Standard could not be assessed. Beech Haven DS0000027723.V322390.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, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Insufficient monitoring of the care plans and risk assessments had led to shortfalls in the recording of health and social needs and risk assessments. Progress was made between the inspection visits to rectify this situation. The evidence that service users and their representatives are fully involved in the processes was not available and would have helped to demonstrate that all of the relevant information has been obtained. More robust procedures and regular monitoring would provide evidence of good management of the medication administration and stock control. EVIDENCE: The Registered Providers were in the process of addressing some of the requirements and recommendations that had been made at the inspection in August 2006, in relation to the risk assessments and care plans. The proposed typing of the care plans would make it easier to involve service users and their representatives and make updating much easier. A new care plan had been almost completed for one service user, with more relevant information regarding their individual needs and in a format which is easy to follow. Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 12 The Registered Providers intend to add information on the social history of the service users which could be of benefit when providing a wider range of activities, particularly reminiscence. Insufficient information was available regarding the service users’ medical conditions and how they are supported, both by the home and by the health professionals. Examples included a lack of information about service users with diabetes, eye problems and dementia. All of the conditions were mentioned elsewhere in the files, but did not have care plans to show how the conditions were being managed or the risks minimised. While the Registered Manager displayed a good personal knowledge of the service users, and the support that they required, there was insufficient evidence in the files to demonstrate that their needs were being fully met or would be understood by the staff team in the absence of the Manager. Service users, and their families, also need to know, and to have agreed, the management of their health needs. When general practitioners, and other health care professionals make visits, they write notes in the care planning files regarding the outcomes. Some were difficult to read. A system is needed to ensure that the notes are recorded legibly in the service users’ records, so that they can be easily communicated to staff, and to service users and their representatives if required. The previous requirements on risk assessments have still not been fully met. Service users and staff need to be aware that all of the risks have been minimised. Many of the manual handling assessments were deemed to be “low”, although the service users’ notes indicated a higher level of risk because of their poor mobility or the need to use equipment. To reduce the risk to the service users, or staff, there must be sufficient information to promote safe handling. The Registered Provider is the manual handling trainer for the home and he, and the Registered Provider/Manager, must ensure the assessments are completed correctly and monitored. If staff members are compiling them, they must have the appropriate training to do so. The administration of the medication, provided weekly from a local pharmacy, in a sealed dosette system, was generally satisfactory. However, some improvement is required to the general administration procedures. There was a lack of information regarding the staff who have been trained to administer the medication or samples of their initials to check against the Medication Administration Record sheets. The Registered Manager was not recording that the medication received into the home had been verified as correct. Only a small amount of non-dosetted or PRN (as and when) medication is used. The packets and bottles had not been dated when opened, so tracking their use was difficult. A course of antibiotics appeared to have been completed and was signed for on each administration. However, one dose remained in the packet. It was not possible to know whether one dose has been missed or only half of a dose administered twice. The Registered Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 13 Manager was advised to keep running totals of the number in stock so that the risk of this type of error can be minimised in the future. The pharmacist was in the home on the last visit of this inspection to provide medication training for the staff. Beech Haven DS0000027723.V322390.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. Service users are offered choices about their daily living preferences, which include the option to stay in their rooms if they prefer to do so. Limited activities are available and insufficient information is provided to the service users for them to be aware of any on offer. Religious and cultural needs are being met in a satisfactory manner. Service users were complimentary about the meals but could be better supported to make choices by the provision of written and accessible information about the menu. EVIDENCE: The majority of the service users spend their days in the large lounge/dining room which overlooks the pleasant garden. Service users who were able to comment on the activities available in the home were not really aware of any organised activities. Those who are more able can go out or read their newspapers and books. They confirmed that they are able to organise their own routines and “do as they wish”. However, not all of the service users are able to choose and usually remain in the main lounge. Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 15 No activities organiser is employed, although a small group of service users were enjoying a game of dominos with a volunteer during the second visit to the home. The individual activities have been recorded, since the last inspection, on the reverse of the daily notes. However, some of those seen to be recorded as “activities” were the general activities of daily living, such as “watching television” or “reading the newspaper”. One service user expressed the view that there was little to do and was not sure of what was available. A regular programme of activities must be made available, in consultation with the service users. Although the small number of service users currently in the home may make the organisation of group activities more difficult, a wellpresented and structured programme of group or individual activities could help to encourage the service users to participate. This could be advertised with a large print newsletter, for instance, or a prominently displayed notice board, and this is recommended. Staff would benefit from receiving specialised training in the provision of activities. The service users’ religious and cultural activities were being met in various ways. Church visitors provide services in the home and those service users who wish to do so visit their own places of worship. The cultural and leisure needs of one service user are catered for by the provision of culturally appropriate meals and satellite television to provide own language programmes. The library service visits regularly and a hairdresser is available to the service users. One service user said this service was available less frequently than in the past but the Registered Manager said that service users could be taken to a hairdressers if this was required. Service users may need to be reminded that this option is available. Visitors were seen on both of the visits to the home. Although some saw their friends and relatives in their rooms, there is also a small lounge available for private meetings. The policy in the Service Users Guide says that visitors are welcome in the home, in accordance with the service users’ wishes, and the service users confirmed this. The two visitors who were met were complimentary about the home. Four questionnaires were received from relatives and visitors and comments, about the staff and owners, included “every one of the staff is friendly and helpful” and “always very welcoming, pleasant and polite”. It was a requirement at the last inspection that the recording of the meals taken by individual service users is made to provide evidence of a satisfactory diet. Since then, the information is included in the daily notes. In some cases, the recordings were in the codes relating to the menu choices for the day e.g. “A and C”. Other staff had recorded them in full, which is more helpful to ascertain whether a balanced diet is provided. Where service users may, for instance, have lost their appetite, staff said this would be recorded in the daily notes although no examples were seen of this. Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 16 One service user was seen to push away a large meal at the first visit. The staff were aware that the service user prefers as small amount of food on the plate and more attention should be paid to accommodating service user’s known likes and dislikes. There is a choice between two main meals at lunchtime. The choices on the first day was chicken or an omelette with potatoes and three vegetables, and an apple pudding for dessert. Fish and chips were served on the second visit with a jam tart and custard for dessert. A traditional menu is served but the needs of one service user, who prefers a more culturally appropriate diet, is accommodated. Although there is a planned menu, the only indication of the choice was posted on a small notice outside the lounge/dining area. It was recommended to the Registered Providers that a more visible menu, either on a board, or placed on the tables, is available so that those service users who are able to do so can be supported to choose more easily. Beech Haven DS0000027723.V322390.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 good. This judgement has been made using available evidence including a visit to this service. Those service users who are able to do so have the confidence to voice their concerns about any major complaint. They felt less included to report any small “niggles” and would benefit from being encouraged to do so. There has been progress in supporting staff to understand and report the safeguarding adults’ procedures. EVIDENCE: Since the last inspection in August 2006, only one complaint has been recorded in the home. This was recorded appropriately and the outcome noted. The few service users who were able to discuss the procedures felt confident that they would be able to voice their concerns should there be a serious problem, although did not feel that they would want to complain about “small matters”. A number of the service users have short-term memory problems, so may not always be able to pass on their concerns to relatives or friends. It is recommended that service users are encouraged to have any comments about meals, activities or other matters, recorded by staff so that the Registered Providers are able to address any issues that arise. A requirement was made in August 2006 that the Registered Providers must ensure that they, and the staff, are fully aware of adult protection procedures and the management of adult protection issues. Since then, the Registered Providers have been on training with the London Borough of Ealing’s safeguarding adults manager and approximately two thirds of the staff team Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 18 have received training. The subject was seen to be included on the staff meeting agenda, as recommended at the last inspection, to ensure that staff awareness is maintained. The Registered Providers reported that they now have the latest safeguarding adults’ handbook for the London Borough of Ealing. No issues have been reported in the home or to the Commission for Social Care Inspection. Beech Haven DS0000027723.V322390.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, 21, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home is well located, close to local amenities and community facilities, which suits the needs of the service users, particularly those who are more independent. Sufficient communal and private spaces are provided for service users to suit their individual preferences. The home would benefit from the programme of refurbishment being carried out as soon as possible. EVIDENCE: Areas of the home were in need of refurbishment at the last inspection, and this included the replacement of the hall and stair carpets. The Registered Providers had, at this inspection, obtained carpet samples for consideration. As a number of areas, particularly on the stairs, are beginning to get worn, an action plan is required to show how soon this work will be carried out. Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 20 A faint odour of urine was present in some areas of the lounge. The Registered Providers have ordered new armchairs which they hope will help to eradicate this problem. Manually operated bath seats are available to support service users to use the baths. However, the manual handling assessments did not take account of any risks to service users or staff when using the equipment and, as recorded elsewhere in this report, need to be more robust. Battery operated devices, which allow fire doors to close when the fire alarm is activated, have now been fitted in a number of doors as required at previous inspections. To improve the home’s infection control, the Registered Providers were asked to make available alternatives to the towels being provided in the toilets. They have done so and paper towels are now provided in all areas, including the kitchen, where there is also a hot air dryer. The Registered Providers said that the service users had a preference for the cloth towels and these had still been retained. However, the Registered Providers said that they recognised the importance of infection control and intend to remove them. Care staff are involved in the cleaning of the home and no separate domestic staff are employed. Apart from the area where an odour of urine was noted, in the lounge, all the areas of the home seen were noted to be clean. Beech Haven DS0000027723.V322390.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. 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. Sufficient staff were on duty to meet the needs of the service users. Although the 50 target has yet to be met, progress has been made on staff obtaining their National Vocational Qualifications. Improvements have been made to the standard of induction and training but some staff still require basic training courses, such as first aid and food hygiene. Staff would benefit from the provision of specialist and enhanced training to better meet the needs of the service users. EVIDENCE: The information from the rotas showed that up to five staff are on duty in mornings and four in the afternoon. There are two waking night staff. . Although staff also undertake all of the care support, activities, domestic and laundry duties, there appeared sufficient to meet the needs of the small number of service users currently in the home. In addition, both Registered Providers are in the home on a regular basis. Staff have been encouraged to undertake National Vocational Qualification training although the target of having 50 of the care staff reaching NVQ Level 2 or above has not yet been achieved. Of the current staff team of sixteen, five have NVQs, one at Level 4, one at Level 3 and three at Level 2. Two staff are in the process of undertaking the qualification and four are due to commence. Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 22 At the last inspection, the Registered Providers were required to evidence that the training, particularly for first aid and fire awareness, was of a suitable quality to demonstrate that staff could gain sufficient knowledge and skills. One Registered Provider has attended a number of “training for trainers” courses, the latest being a first aid course in January. He is also qualified to deliver courses on manual handling. It was a recommendation, by the London Fire and Emergency Planning Authority, that he attends a Fire Marshall’s course and is now providing instruction to the staff on fire awareness. Although on the day of the second visit of the inspection, the pharmacist was visiting to undertake medication training, the Registered Provider now carries out most of the training. Videos are used for subjects such as dementia. It is recommended, however, that specialist training is provided, wherever possible, by trainers with particular expertise in the subject. From the records and information provided, there is still core training outstanding. The majority of the staff have attended courses on manual handling, fire awareness and infection control. As the Registered Provider had only just completed the first aid trainer’s course, most of the staff still required this training. Not all staff have attended food hygiene courses and some required updated training. The Registered Providers indicated, shortly after the inspection, that they had arranged for this to take place by the end of March. A training and development plan for each staff member needs to be introduced to show the outstanding courses they require, in addition to those which are needed for their personal development. Evidence was required at the last inspection that all of the documentation on recruitment, to maximise service users’ safety, must be in place. Two additional staff have recently been recruited but had not commenced work. Criminal Records Bureau disclosures have been applied for but references had not yet been taken up. The Registered Providers said that they would not be employed until the checks had been completed. Evidence was provided to show that existing staff have the correct documentation to enable them to work in the home. Information on contract hours was not available as the staff are not issued with Contracts of Employment and are not employed with set contract hours. The Registered Providers were advised that a copy of each staff member’s job description should be included in their file, so that their roles and responsibilities are clearly defined. Information on terms and conditions should also be provided. A new, comprehensive, induction procedure has been introduced which will involve staff in completing a workbook covering the “Skills for Care” programme. A sample of a completed workbook was seen. The Registered Providers said that all of the staff will be encouraged to complete this as they felt it was a useful training aid. It was discussed with the Registered Providers that evidence of the staff induction is required to be held for inspection. Beech Haven DS0000027723.V322390.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The general management of the home is still in need improvement to meet the National Minimum Standards and the Care Home Regulations 2001 fully. Some progress has been made in identifying the shortfalls, through a new quality assurance programme, but the Registered Providers need to take a more active role in ensuring that delegated tasks are being carried out to a good standard. More regular team meetings and supervision would improve support for the staff team. EVIDENCE: Both the Registered Provider and the Registered Providers/Manager have completed the Registered Managers Award and were awaiting their certificates at the time of the inspection. They have owned and managed the business since 1986. Both are involved in the running of the home on a daily basis, with Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 24 the Manager being more involved in the care work than with the administrative processes. Because of the past and current requirements around the quality of the care records, the Registered Manager needs to demonstrate that she monitors the outcomes of the tasks that she delegates to other staff. Some progress had been made by the second visit of the inspection, but the Registered Manager must take the responsibility for ensuring that ensure that regular monitoring is carried out and that the lines of accountability are clear. The home has a relaxed and pleasant atmosphere. The service users, and their representatives who were met or responded to the questionnaires, expressed their satisfaction with living in the home. No review of the quality of care has taken place but the Registered Providers have now obtained a full quality assurance auditing system and had just commenced work on this. Service users’ meetings have been taking place, but it has been a long outstanding requirement that there is a quality review, which should include consultation with all of the service users and their representatives, and this needs to be completed to demonstrate where the home can develop and improve. Each service user has small individual safe in their bedrooms where they are able to lock their personal items. The Registered Providers confirmed that they do not manage the finances of any of the service users and will invoice the service users or their family members for any money spent on their behalf. The Registered Providers had details of a new advocacy service for people with dementia and had received a visit from a member of the organisation. Not all of the staff have received regular one-to-one supervision. While records seen indicated that some sessions have taken place, this has not been extended to all of the staff team or been held on a regular basis. Both of the Registered Providers and the senior staff are involved in supervision and, with a staff team of sixteen, the task of reaching the National Minimum Standard of six sessions a year for each staff member, should not be onerous. This could help to ensure that all of the staff are supported fully in their work. The Registered Providers had commenced the keeping of a schedule to show when staff have received supervision. Staff meetings are now being held every two months and it is recommended that these are held more frequently to ensure that all the staff have the opportunity to attend on a regular basis. It was required at the last inspection that record keeping in the home needed to improve. The Registered Providers had made progress by the second visit of this inspection, although some of the systems were still being developed. The lack of monitoring of the records has been a concern and the Registered Providers are now aware that they must undertake regular checks on the work they delegate. As it is owned and managed by the Registered Providers, the Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 25 monthly visits, under Regulation 26, are not required. However, a similar, detailed audit is recommended so that it can be demonstrated that regular monitoring takes place. The London Fire and Emergency Planning Authority last visited the home in September 2006. All staff have now had fire training but not all had taken part in a recent fire drill. The fire risk assessment, compiled in accordance with the new fire legislation introduced in October 2006, still needs completion. The Registered Providers was advised to check with the London Fire and Emergency Planning Authority for information on completing a risk assessment for a care home, which is now available. The fire extinguishers were last checked in January 2006, and the alarm system was being serviced during the inspection. The fire alarms are tested every Friday, with a selection of the fire points being tested each week. A sample of the home’s maintenance records was examined. One of the Registered Providers checks the small electrical appliances and this was completed in January 2007. The annual Legionella check was carried out in June 2006. A new call bell system has recently been installed. The Registered Providers said that the lift is serviced every two months. Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 26 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 2 2 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 2 2 2 Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS \,his 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 (1) Requirement When fully revised, the Statement of Purpose and Service Users Guide must be provided to service users. Sufficient information must be provided and recorded to show that a full assessment of need has been carried out and service users are only admitted whose needs can be shown to be met. The Registered Providers must demonstrate the home has the capacity, in terms of facilities, staffing, and training, to meet the service users’ needs. The home’s aims and objectives must reflect the services offered. The risk assessments for service users must be completed and reviewed on a regular basis. (Previous timescale of 31/10/06 not met) All manual handling risk assessments must be completed, by staff trained to do so, to show how the risks will be minimised and the equipment which is to be used to maximise safety. (Previous timescale of 31/10/06 DS0000027723.V322390.R01.S.doc Timescale for action 31/03/07 2 OP3 14 (1) 15 (1) 31/03/07 3 OP4 14 (2) 15 (2) 31/03/07 4 OP7 13 (4) 31/03/07 5 OP7 13(4),18(1) (c)(i) 31/03/07 Beech Haven Version 5.2 Page 28 6 OP8 12(1)(a),13 (1)(b) 7 OP9 13 (2) 8 OP12 16(2)(m), (n) 23 (1)(a) (2) (b) 9 OP19 10 OP30 18 (1)(c)(i) 11 OP33 24 12 OP36 18 (2) 13 OP37 17(1)(2) (3) 14 OP38 23 (4a)(b) not met) There must be clear evidence that service users’ health needs are addressed and the treatment they receive must be recorded. (Previous timescale of 31/10/06 not met). Robust procedures for handling medication must be in place, together with evidence of regular monitoring. A regular programme of activities must be provided, in consultation with the service users. An Action Plan is required to show when the refurbishment work, including the replacement of carpets and furniture, will commence. Previous timescale of 30/09/06 not met). Staff must be shown to have undertaken all of the basic training courses, including first aid and food hygiene, required to support the work they perform. A review of the quality of care must be carried out. A copy of the report of findings must be forwarded on to the CSCI. (Previous timescale of 30/11/06 not met) Staff supervision must take place on a regular basis and evidence made available to confirm this. (Previous timescale of 31/12/06 not met) Record keeping must be maintained in good order, with regular monitoring evidenced, to ensure that all of the records required are accurate and up-todate. A fire risk assessment must be completed in accordance with the new legislation. 31/03/07 31/03/07 30/04/07 31/03/07 30/04/07 31/05/07 30/04/07 31/03/07 31/03/07 Beech Haven DS0000027723.V322390.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 That, to encourage the service users to participate in a structured programme of group or individual activities, these are advertised with a large print newsletter, or on a prominently displayed notice board. That the staff who carry out activities have the specialised training to do so. That a more visible menu, either on a board, or placed on the tables, is available so that those service users who are able to do so can be supported to choose more easily. That service users have the opportunity to have recorded any comments on meals, activities or other matters, so that the Registered Providers are able to address any issues that arise. That specialist training is provided, wherever possible, by trainers with particular expertise in the subject. That staff meetings are held more frequently to ensure that all the staff have the opportunity to attend on a regular basis. That the Registered Providers look at undertaking a regular monthly audit, on the lines of a Regulation 26 visit, to provide evidence of regular monitoring being undertaken. 2 3 4 OP12 OP15 OP16 5 6 7 OP30 OP36 OP33 Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection West London Area Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE 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. Extracts may not be used or reproduced without the express permission of CSCI Beech Haven DS0000027723.V322390.R01.S.doc Version 5.2 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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