Inspection on 26/01/06 for Beech Haven

This inspection was carried out on 26th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 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 Haven 08/08/05

Beech Haven 03/03/05

Beech Haven 28/07/04

Beech Haven 04/03/04

Similar services:

Flint House

St Vincents

The Cotswold Home

Fairways

Newbeech House

Winton House

Treloar College

Rush Court

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

CARE HOMES FOR OLDER PEOPLE Beech Haven 77 Burford Road Chipping Norton Oxfordshire OX7 5EE Lead Inspector Jane Handscombe Announced Inspection 26th January 2006 09:45 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 DS0000013064.V270393.R01.S.doc Version 5.1 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 DS0000013064.V270393.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech Haven Address 77 Burford Road Chipping Norton Oxfordshire OX7 5EE 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) 01608 642766 01608 644290 Maricare Limited Care Home 23 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (23), of places Physical disability over 65 years of age (2) Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The total number of persons that may be accommodated at any one time must not exceed 23. The admittance of one named resident under the age of 65. Date of last inspection 8th August 2005 Brief Description of the Service: Beech Haven is situated on the outskirts of the market town of Chipping Norton and is on a bus route. The home provides accommodation and personal care for up to 23 male and female service users aged 65 and over. District nurses visit the home to provide nursing care. There are 23 single bedrooms situated on the ground and first floors. Eight of these rooms have an en-suite toilet and all rooms have a washbasin. There are three assisted baths, one on the ground floor and two on the first floor, as well as separate toilets. There are two lounges and a separate dining room. There is a large garden of approximately half an acre that is accessible to service users and visitors. Disabled access is provided. Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an announced inspection, which took place on the 26th January 2006. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The visit involved speaking to residents in order to ascertain their views upon the care and the services they receive at the home, the staff members and the newly appointed manager, viewing care plans and assessments, whilst observing the general day to day operation of the home. At the time of inspection the service users were busy going about their daily activities and there was a calm relaxed atmosphere. The inspector was warmly welcomed, by both the staff and service users, on arrival. Much of the inspection focused upon life from the service users’ point of view, who were complimentary about the care received, services offered and the dedicated staff. Overall, the general picture of the home gained by the inspector was of being a well organised and caring home with a dedicated team of staff who offer a client focused approach to the care provided. What the service does well: What has improved since the last inspection? Since the previous inspection, the home has undergone further development, in that another 6 bedrooms all with en-suite bathrooms have been built so as to extend the service and are due to be completed in March 2006. With this in view a new manager has been appointed and is presently undergoing registration with the Commission for Social Care Inspection. The new manager has been developing a programme to offer a wider range of activities to the residents, has reviewed the recording systems in place and introduced a new training session on care planning, which is delivered by a consultancy and all care staff have attended. Staffing hours during the night time have been extended from those which were previously provided for. Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 All prospective service users undergo an assessment of needs to ensure that both parties are confident that these needs can be met. EVIDENCE: A full care assessment is carried out with individuals before they are admitted to ensure both the home and prospective service user are satisfied that it will be able to meet these assessed needs in full. Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 9 and 11 Each resident has an individual comprehensive plan of care drawn up from an initial assessment of needs, which is reviewed regularly and changed accordingly to ensure that the residents’ needs are met. EVIDENCE: The manager has introduced a new training session on care planning, which is delivered by a consultancy and which all staff have attended. Care plans were found to set out in detail the action that needs to be taken by staff to ensure that all aspects of the health, personal and social care needs of the resident are met. The plans included risk assessments for both the residents and the staff and actions necessary to minimise any risks apparent. There were a couple of omissions found, around personal inventories, in which these had been unsigned, however the manager assured the inspector that these would be sought and rectified. One resident’s needs had changed and an emergency care plan had been put in place superceding the previous care plan, which all care staff were aware of; however this was not stated clearly on the care plan and the inspector found this to be confusing. The manager informed and showed evidence to the inspector that usually emergency care plans clearly state that they supercede Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 10 others, however the one in question was rectified immediately. The registered manager monitors the care plans on a monthly basis and updates them where necessary to reflect the changing care needs. Nutritional assessments were included in the care plans and appropriate action taken where necessary. Residents are protected by the home’s policies and procedures for dealing with medicines. There are clear procedures for the recording, storage, handling, administration and disposal of medicines and these were generally found to be adhered to; however there was one incident with regard to a missing signature for administration of one resident’s medication, this was discussed with the manager and dealt with appropriately during the inspector’s visit. Residents are able to take responsibility for their own medication within a risk management procedure, although there are no residents at present who self administer. Staff liaise with GPs if a concern arises. Service users and their families are assured that at the time of death, they will be treated with dignity and respect, and their spiritual needs and associated rites will be observed. Every effort is made to ensure the best possible care is provided at this time and support to the families and friends through what is a very difficult time. Information about the residents’ wishes at their time of death is obtained wherever possible at the time of their admission to the home, and this was observed on examination of the care plans. . Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 The home is committed to maximising each resident’s capacity to exercise personal autonomy and choice. EVIDENCE: There are few routines at Beech Haven and these are centred around meals and mealtimes. Wherever possible the service users are enabled to follow their social, cultural, religious and recreational interest and needs. The staff make every effort to find out what the individual’s lifestyle and preferences are and these were seen to be documented in the care plans. The manager has been developing the activities programme to provide a wider range of activities to suit the residents’ needs. One resident informed the inspector that she takes a taxi into Chipping Norton weekly and visits the local hairdresser, whilst another enjoys going into the town. The inspector was informed that some residents were going to a pantomime that evening. The inspector was told ‘we have a meeting regularly and we can tell the manager what we like or don’t, she listens and is very good.’ Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 The home demonstrates that the residents’ legal rights are protected. EVIDENCE: The home facilitates access to advocacy services for those who require them. Steps are taken to ensure that the residents are able to vote in elections either by postal vote or visiting the local polling station, for which transport is provided. The local MP has visited the home on a number of occasions and is invited to speak to the residents. Residents are able to maintain links with the local community and there are opportunities for political club membership in which the residents attend meetings and lunches outside of the home. Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 26 All areas of the home, viewed during the inspection were found to be clean, hygienic and free from offensive odours. EVIDENCE: The home provides safe, comfortable well maintained surroundings, which are equipped to meet the residents’ needs and presented as clean, tidy and free from any offensive odours during the inspection. The home provides accommodation for each resident, which is furnished and equipped to ensure comfort and privacy and meets the residents’ needs. All bedrooms are redecorated on vacancy. Residents are encouraged to bring small items of furniture, space permitting, memorabilia, and ornaments in order that they can personalise their own rooms to their liking. Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 and 30 The home follows a thorough recruitment process to ensure that residents are in safe hands and training opportunities are readily available to all staff to ensure competency in their roles and to allow for personal development. EVIDENCE: There is a good feeling of team work amongst all the staff and those spoken to are very happy to be working at the home, and appreciate their colleagues and the support they give each other. A sample of staff files was viewed which showed that there are good systems in place with regard to the recruitment of staff. However, it was noted that 2 files failed to contain copies of references and upon questioning the manager, the inspector was informed that no staff were taken on before references had been gained and all checks undertaken. Since the manager was unable to lay her hands upon the references during the visit, the inspector made a requirement that copies of the references be forwarded to the Commission. The Inspector received references as required, however it was noted that these were dated after the inspection was undertaken. All new members of staff undergo induction training, upon appointment to their posts, and are offered ongoing training and encouraged to undertake the National Vocational Qualification (NVQ) in care, which equips them to meet the assessed needs of the residents within the home and allow for personal development. Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 36 and 37 Those living at Beech Haven are confident that the home is well managed and that they benefit from the management and the ethos of the home. The home is run in the best interests of the residents. EVIDENCE: A manager has been in post since the last inspection and is currently undergoing registration with the Commission for Social Care Inspection, she has had previous experience of running care services and has settled in with the residents and staff at Beech Haven. The manager informed the inspector that a consultancy company has been appointed for the purpose of designing a quality assurance questionnaire to seek the views from all residents and relatives and likewise an activities programme questionnaire is presently being worked upon. Residents are also able to voice any concerns and compliments during the residents meetings which are regularly held in the home. Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 16 All staff undergo supervision sessions and appraisals as prescribed by the national minimum standards. Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 17 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 x x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 x 9 3 10 x 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 x 14 3 15 x COMPLAINTS AND PROTECTION Standard No Score 16 x 17 3 18 x x x x x x 3 x 3 STAFFING Standard No Score 27 x 28 x 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 x x x 3 3 x Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 18 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 OP29 Regulation 19 Schedule 2 19 Schedule 2 Requirement The manager must re-obtain and forward copies of references for the two identified members of staff to CSCI. The manager must ensure that staff do not commence duties until 2 satisfactory references have been received. Timescale for action 26/01/06 2 OP29 26/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Beech Haven DS0000013064.V270393.R01.S.doc Version 5.1 Page 20 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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