Inspection on 29/08/06 for Beech Haven

This inspection was carried out on 29th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Beech Haven 09/05/07

Beech Haven 17/01/07

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 10:10 29th August 2006 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.V300134.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.V300134.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.V300134.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include OP and PD(E) not to exceed 30 persons 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 user’s assessed needs and care plans 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. 15th November 2005 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, with one variation 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 easily 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 second 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 facilities on each floor. A passenger lift goes to the second floor 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.V300134.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 29th and 30th August 2006 between the hours of 10am and 5.55pm. The Registered Provider and the Registered Provider/Manager were both present during the visits. The inspection process took a total of eight hours. The home had twenty service users, one of whom was in hospital. The majority of the service users were met during the course of the inspection, mainly in the lounge/dining area. Two service users chose to remain in their bedrooms. On the second day of the visit, two of the service users were at a day centre and the review for one service user was taking place with a Social Services representative. The hairdresser and a minister of religion were also in the home. Approximately one third of the bedrooms, and all of the communal areas were seen, when the home was toured with the Registered Manager. Discussions were held with five of the staff team. The home is registered for older people and those with physical disabilities. A variation to accommodate three service users with dementia had been granted in January 2006 but only one of the service users now lives in the home. However, it was noted in the course of the inspection that a number of service users might have the early stages of dementia, although the Registered Providers said that none had been diagnosed with this condition. Records and documentation were examined, including care plans, staff and training files, and maintenance schedules. At the previous inspection, in November 2005, nine requirements were made of which six have been met. One of the Registered Providers, who is responsible for the majority of the administration and training in the home, was still in the process of completing the overdue requirements, which have been repeated. The Registered Manager must ensure that all of the requirements, including the additional thirteen made at this inspection, are met within the timescales given. What the service does well: The service users spoken to during this inspection found the home to be suitable for their needs, particularly with its proximity to local amenities, and said that a good level of support is provided. The service users were complimentary about the choice of meals and the food provided. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 6 There are sufficient communal and private spaces for the service users to choose to spend alone or in the company of other service users. What has improved since the last inspection? What they could do better: There are outstanding requirements, from the inspection in November 2005, which require completion. The Registered Manager needs to oversee the process of completing these to ensure compliance with the Care Home Regulations 2001. These include consultation with the service users to develop and improve the service. The work on the general risk assessments had not yet commenced and these must be completed to minimise any risks to the service users. The manual handling risk assessments also need to be more robust and undertaken by a trained risk assessor. Not all of the documentation is available, in sufficient detail, to support prospective service users, and their representatives, to make an informed decision about living in the home. Amending the Statement of Purpose, which needs to include information such as the complaints procedure and room sizes, will assist them with this process. The terms and conditions need to be available to all of the service users in the home. More thorough care planning would provide staff with all of the information they require to support service users more effectively. The information was not always found to be fully completed. The requirement, from the previous inspection, to have the evidence that service users’ health needs are addressed, together with the treatment they receive, has not been fully met. Whilst meals ordered by service users are recorded, the meals that they have actually taken have ceased to be recorded and there is little evidence of suitable diets being provided to each individual service user. The recording system had been in place for this to be carried out but there is insufficient monitoring by senior staff to ensure that the records are being maintained. The home is in need of some refurbishment, including the replacement of carpets and furniture. An Action Plan is required to show when the refurbishment work will commence. A number of the fire precautions need to be improved. Some service users wish to have their bedrooms doors open and must be enabled to do so safely by the fitting of suitable door closing devices. There was no evidence that all of the staff team have attended regular fire drills. Whilst in-house training has been given for fire awareness, the Registered Providers need to take advice to ensure that the training given is sufficient and meets London Fire and Emergency Planning Authority guidance. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 7 To support the infection control precautions in the home, hygienic hand drying facilities should be provided in each toilet. The recruitment processes are generally satisfactory, with staff having full Criminal Records Bureau disclosures before commencing work. Improvements are required, however, to ensure that all of the references are taken from the most recent or relevant employer, with the full employment history known so that dates can be verified. Record keeping, in a number of areas, need to be maintained in better order, and all of the records required under Schedule 3 & 4 of the Care Home Regulations 2001 kept up-to-date and readily available for both announced and unannounced inspections. The training records had not been updated, or available in sufficient detail, to show that all of the staff have the required induction and training. The majority of the training is provided in-house, by one of the Registered Providers. Access to training by professionals, particularly for fire awareness and first aid, where specialist equipment is used, must be considered. Evidence of staff support, from the Registered Manager, needs to be shown by regular supervision sessions, team meetings, and the production of training and development plans. Good practice recommendations have been made to assist the management and staff to develop more effective systems. Introducing a system, which keeps records maintained in accordance with the Schedules of the Care Home Regulations 2001, would greatly improve the efficiency of record keeping and provide easier access for staff. Maintaining simple schedules of supervision sessions, fire drills attended and maintenance frequencies would also provide better evidence of compliance. Involving service users and their representatives in the care planning process would be better enabled by the production of typed care plans, copies of which they should have. These would also facilitate easier updating and staff access. 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 DS0000027723.V300134.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.V300134.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 (6 does not apply in this home) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some of the documentation requires updating to ensure that new and prospective service users, and their representatives, have all of the information they require to make an informed decision about moving to the home. All service users need to be issued with contracts/terms and conditions so that they are fully aware of any obligations, as well as being informed of the services and facilities. Assessment procedures for new service users are satisfactory. The needs of some service users are changing, and the Registered Providers must ensure that these can continue to be met within the home’s categories of registration. EVIDENCE: The Service Users Guide and Statement of Purpose have been amended by the Registered Providers and copies were provided. However, the Statement of Purpose was not complete and needs to be amended in accordance with Schedule 1 of the Care Home Regulations 2001. In particular, the complaints procedures and room sizes need to be added. This, together with the Service Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 10 Users Guide, will assist service users, their representatives and professionals to have all the information they require to make a decision about moving to the home. The Service Users Guide will also need to include a summary of Statement of Purpose, when this is completed. Contracts have been provided to those service users who are privately funded. Where the local authorities have commissioned services, the service users had not been issued with terms and conditions, although had been given information on the fees payable. The Registered Providers undertook to ensure that all of the service users have the appropriate contract/terms and conditions, so that they have the full information regarding the facilities and services that the home offers. Service users referred to the home by local authorities have needs-led assessments provided and a sample of one of these, for a new service user, was seen. The Registered Providers said that they undertake all of the assessments for the home. Wherever possible, prospective service users are encouraged to attend the home and one service user confirmed that Beech Haven had been among a number of homes they had visited. The Registered Providers said that service users are not always well enough to do so and it is often families who make the decision about the home. The Registered Providers confirmed that, as previously required, service users are now receiving a letter, prior to admission, informing that the home is able to meet their needs. The home is registered for older people and people with physical disabilities. However, a variation to the registration had been in place for three service users with diagnosed dementia to be accommodated and the Registered Providers found that their needs could be met without changes to the staffing levels and facilities. Two of the service users are no longer in the home and the variation remains in place for one service user only. During this inspection, a number of the service users met may have early stage dementia. The Providers said that none had been diagnosed but they will need to ensure that any service users are referred to the appropriate health care professionals to ascertain any medical needs. Where it is possible for their needs to continue to be met, within the home, a variation to the registration would need to be sought from the Commission for Social Care Inspection. The Providers will, however, need to reconsider the home’s categories of registration should the number of service users with dementia continue to increase. The Registered Providers are aware that they must not admit service users with a diagnosis of dementia. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Although care planning information is in place, and service users and the representatives are now having input into this, not all of the service users’ needs are fully documented. Health needs are not always sufficiently detailed to show how they are being met and the outcomes not always recorded. To minimise the risks to service users, whilst working to retain their independence, the work on the general risk assessments must be completed. Insufficient detail on the manual handling assessments does not assist staff to support the service users and reduce risks. Service users were able to confirm that they were treated with respect by staff and have every opportunity to retain their privacy. EVIDENCE: Five of the service users’ care plans were examined. It was seen that action has been taken to include service users or their representatives in the process of the care planning, as required at the previous inspection, although they had not been provided with copies of the care plans. Although the care plans seen Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 12 were mostly legible, it is strongly recommended that consideration is given to having them typed, rather than handwritten. This would allow for easier updating after reviews and provide service users and their families with a copy which would encourage their involvement. While the plans detail various aspects of the service user’s care needs and the action taken to support them, further detail was needed in some areas. In particular, the health needs of the service users were not always shown on the care plan and, where they were shown, it was not clear whether or not ongoing medical assistance was required. In one case, the outcome of tests for one service user was not found in the documentation. While the Registered Provider/Manager may be fully aware of the service users’ needs, and outcomes of health care, not all of the staff would necessarily be and it is essential that this information is documented if, for instance, the Registered Manager is absent. Separate notes are completed when health care professionals visit, or are visited, and the general practitioner or district nurse sometimes records these. However, it needs to be ensured that those which are not fully legible are recorded elsewhere in the notes so that staff are aware of any outcomes. A monthly review of the care plans was seen to be taking place. Service users are offered the opportunity to have a general practitioner of their choice and a list of local surgeries is provided in the Service Users Guide. Notes are kept by both day and night staff to support the service users’ well being and to provide continuity. The samples seen were satisfactory. Staff said that the night staff check every hour during the night, except where service users have requested that this is not done. This information was not seen in the service users’ care plans examined and should be recorded to ensure that their wishes are known and their health and safety needs have been assessed. It was a requirement at the previous inspection, in November 2005, that the general risk assessments for service users must be in place and reviewed regularly. One of the Registered Providers had commenced the production of a risk assessment form and check list of the risks which would need to be considered. The timescale of December 2005 had not been met and the forms are not in use. For the safety of the service users and staff, the Registered Providers must demonstrate that all of the areas of risk that service users might encounter have been considered. Any action required to reduce the risk, and the equipment to be used, must be recorded. Any which involve restrictions, including the use of bedsides, must be documented, and agreed with the service users or their representatives. One of the Registered Providers is undertaking all of the manual handling risk assessments but these were not found to contain any risk reduction plan. The risk assessment for one service user did not, for instance, specify how staff work with a service user who cannot weight bear. Although updating his Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 13 training in manual handling, on a regular basis, the Registered Provider has not been trained in carrying out risk assessments. Those staff undertaking risk assessments should be trained to do so. The manual handling risk assessments need to be more robust and show how the staff are supported to lessen the risk the service users and to themselves. One service user self-medicates but no risk assessment was in place for this and needs to be completed. This should include an agreement to keep the medication safe and a locked storage facility is provided for this purpose. The medication for the home is kept in locked storage, within a secure cupboard with a keypad. The local pharmacist, who also undertakes training with the staff, provides a weekly dosette box system. The medication is overseen by the Registered Manager and a limited number of staff are involved in administering medication. A list of those trained to give medication should be available. There were no PRN (“as and when”) medications or homely remedies in the medication cupboard and the Registered Manager confirmed that no PRN, homely remedies or controlled medication are being used at the present time. The service users who were spoken to said that they were treated well by the staff team and had no complaints about their care and support. There had been one complaint regarding a staff member not knocking when entering a bedroom, but this was resolved. The Registered Providers were seen to have followed this up to prevent reoccurrence. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users confirmed that the daily life in the home suited their needs and that activities are provided for those who wish to participate. Some service users enjoy going out to church, a luncheon club, or with family and friends. The service users were complimentary about the meals provided. However, the systems in place to demonstrate choice and opportunity about meals and activities need to be reintroduced and maintained, particularly while the home is without a full complement of staff to carry out activities. EVIDENCE: One of the people providing activities no longer attends the home, and there is one person, for one day a week, providing activities at present. The Registered Provider said that staff also carry some activities, such as games and quizzes, and he is intending to provide additional staffing for activities. Two of the service users visit the Age Concern luncheon club twice a week and one expressed her enjoyment at being able to do so. Two service users currently go out unaccompanied. Several more have family and friends who visit or who accompany them out. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 15 One service user enjoys watercolour painting, which can be pursued in the home. The mobile library visits monthly and two service users were seen to be enjoying reading. A variety of books and games are also available in the home. All of the bedrooms seen had their own televisions and, in part of the main lounge, a television was on. As the lounge is large, it is possible for service users to sit in quieter areas and the television was not particularly intrusive. One service user’s cultural needs are met by satellite television from her country of origin. Service users are able to fulfil their religious needs by visits to local churches and also have services and communion within the home. Some service users said that they particularly enjoyed sitting near to the home’s garden, which some bedrooms also overlook. Two service users went out locally with a member of staff during the inspection and the Registered Manager said that she is able to take small numbers of the more mobile service users out in her seven-seater transport and trips to Richmond Park and the Christmas lights had been enjoyed. There is, unfortunately, no transport for those service users with mobility problems and the home had not been able to access the local community transport. Service users confirmed that they were able to exercise choice in the home by deciding where to spend their time. Two of the more recently admitted service users chose to spend their time in their bedrooms and, although the Registered Provider said that they would be encouraged to go to the dining area for meals, this is a matter of personal choice. One service user said that she enjoyed the company in the main lounge, so chose to say there for most of the time. The smaller lounge is not reported to be well used but is available for reviews, private meetings or seeing visitors. There is a telephone available for the use of service users but several either have their own line or a mobile phone. The minutes of only one service users’ meeting for 2006 was seen although the Registered Provider said that another had been held to discuss the menu. More regular meetings, perhaps in small groups, would provide the Registered Providers with evidence of consultation for their review of the quality of care, which is an outstanding requirement. Service users were complimentary about the food and confirmed that they are able to have a good choice. Two meals, lunch and an evening meal, observed during this inspection. Lunch was soup, a choice of two main courses, pork or chicken, and trifle or ice-cream. The evening meal consisted of pizza or macaroni cheese bake and salad, with fruit salad for dessert. Three service users have special diets, one vegetarian, one diabetic and one service user has a specific ethnic diet. There is provision in the daily notes for the recording of meals taken and participation in activities but the samples examined showed that these were not being completed. While staff sometimes note if the service users ate well, Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 16 or had a poor appetite, little recording was seen to demonstrate that individual service users are receiving a varied and nutritious diet. The Registered Provider spoke to the senior staff about reintroducing this monitoring as soon as possible. Beech Haven DS0000027723.V300134.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Only one complaint had been made since the last inspection which was satisfactorily resolved. The Registered Providers need to ensure that they are fully conversant with the adult protection procedures as they had not attended management training and did not have the current Local Authority procedures. EVIDENCE: The Registered Providers confirmed that there had been one complaint since the last inspection in November 2005. This was seen to have been resolved to the satisfaction of the service user and also seen to have been followed up to ensure that the service user remained happy with the outcome. Although service users said that they had no complaints with the home or staff, more consultation with the service users, on a regular basis, would give them the opportunity express any small concerns they may have. As previously mentioned, details of the complaints procedure must be included in the Statement of Purpose. There have been no adult protection issues in the home. Staff training has been provided on the Protection of Vulnerable Adults by the use of a video. The Registered Providers had not attended any management training courses on the safeguarding of adults and it is recommended that they do so. It was also recommended that the Registered Providers that the subject of safeguarding adults is placed on the staff meeting agendas as a regular item Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 18 so ensure that staff remain aware of the subject. The Safeguarding Adults procedure for the London Borough of Ealing was not available and the Registered Providers undertook to obtain this. Beech Haven DS0000027723.V300134.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 23, 25, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some areas of the home are in need to refurbishment, including the replacement of some carpets and seating in the communal areas. Private spaces were seen to be satisfactory and personalised. Better infection control precautions are needed in the toilets. Service users should have the option of having their bedroom doors left open, and the Registered Providers need to provide equipment for to minimise any fire risk. EVIDENCE: The home is maintained in a reasonable condition but there are areas which require upgrading. The stair carpet in some areas has signs of wear, particularly on the stairs, and needs replacement before there is further damage. The Registered Providers said that refurbishment is planned, which will include new carpets, chairs and dining furniture. An Action Plan is required to show then this work will be completed. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 20 Although service users have a choice of lounges, the larger lounge, which also has a dining area, is more popular with service users. A number of service users said that they like to sit near to the garden. The second room, which is in the front of one of the houses, provide a private area for meetings, visitors or a quiet space. There are adequate bathrooms and toilets in various areas of the home, and there are assisted bathing facilities. Several of the service users have zimmer frames or wheelchairs. The corridors in the home are quite wide and service users were seen to be able to negotiate them. The home has two lifts, one of which is central to the communal rooms. The second lift is not in use but the Registered Manager said that it could be recommissioned if required. Approximately one third of the bedrooms were seen. Although sizes vary, the rooms are mainly of a good size and are able to provide the service users with sufficient space for their needs. The occupied rooms were pleasantly personalised with pictures and photographs. The size of the rooms needs to be included in the Statement of Purpose so that prospective service users have access to this information. All rooms have a wash hand basin, and nine have an en suite toilet. A number of the rooms seen were vacant and had been, or were to be, decorated by the home’s handy person, prior to being occupied again. It was noted that hospital style beds are used which may not be a necessity, as the home does not provide nursing care. Service users may prefer a different style of bed and should be offered the choice. There have been no visits from the London Fire and Emergency Planning Authority officers for some time. The Registered Providers were recommended to seek their advice at the last inspection but had not done so. A request was made, by the Commission for Social Care Inspector, for a fire officer to visit to examine the fire precautions. It was noted at the last inspection that a small number of service users like the doors of their rooms to remain open, one during the night. None were seen to be propped open on this visit but would have to be, if the service users’ requests are to be met, as there are no automatic door closures. The Registered Providers said they would obtain the necessary battery operated devices to enable service users to have a choice. The areas of the home seen on this inspection were clean and hygienic. However, one toilet did not have any hand-drying facilities and others had only cotton hand towels. It was discussed with the Registered Manager that these can be unhygienic and other systems, such as disposable towels or hot air dryers, need to be provided. It was a requirement at the last inspection that the staff were trained in infection control and one of the Registered Providers has undertaken this training with staff, with the use of videos. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Continuity is provided for the service users by having a regular staff team, without the use of agency staff. The majority of the training is provided inhouse and the records do not evidence that all of the staff are fully trained. Not all of the staff records provided evidence of a robust recruitment procedure. EVIDENCE: The Registered Providers reported that there are no staff vacancies at present and four staff had been employed recently. Three of their records were examined. Whilst generally satisfactory, it was noted that one reference could have been obtained from a recent employer and this should have been carried out. There were gaps in the employment histories which need to be explored with the staff and dates of employment need to be verified. Criminal Records Bureau disclosures were in place and had been obtained before employment commenced. No agency staff are used in the home and cover is provided from within the regular staff team. In addition to the Registered Providers, there are two supervisory staff, one working on the weekday early shifts and one of the late shifts. One has a National Vocational Qualification Level 3 and is taking Level 4. The other has Level 2 and is undertaking Level 3. Eight of the fourteen staff have or are taking National Vocational Qualifications and this will meet the 50 target if completed. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 22 One of the Registered Providers is a manual handling trainer and has annual refresher training. He confirmed that the new staff have received manual handling training. However, a schedule, for demonstrating the complete record of staff training, had not been updated. The four new staff have induction records, which were seen but were found to be fairly basic. The Registered Provider said that he was awaiting new information from Skills for Care (formerly TOPSS) on staff induction and would amend the induction procedures, to meet them, in due course. The Registered Provider runs the majority of the training courses in-house, using videos. Some distance learning courses are in use, including one for dementia. It was discussed with the Registered Provider that some of the courses, such as first aid and fire training, may need additional expertise, particularly when staff require the use equipment to demonstrate competency. It needs to be demonstrated that staff are trained to a good standard. Evidence was seen in the files of new staff where training course have been undertaken with their previous employers. The Registered Providers need to collate the information to show that all of the staff team have the induction, basic courses and advanced training required for their own development and to meet the assessed needs of the service users. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home has a relaxed atmosphere, and service users and staff generally expressed satisfaction with the home, there are areas where improvements are required. In particular, those which evidence the good management of care planning, risk assessment, staff training and maintenance records. Service user satisfaction and consultation need to be demonstrated as being undertaken regularly. Where requirements are made, these must be completed within the timescales given and not remain outstanding. The roles and responsibilities of the Registered Provider, Registered Provider/Manager and senior staff are not clearly enough defined to support the smooth running of the home and ensure that tasks are completed and monitored effectively. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 24 EVIDENCE: The Registered Providers, one of whom is the Registered Manager, work in the home on a daily basis. The Registered Manager has a nursing qualification and has nearly completed her Registered Managers Award, which the other Registered Provider is also undertaking. During the course of this inspection, it was not always clear who had responsibility for overseeing tasks, including care planning, supervision and the maintenance and monitoring of records. The Registered Manager needs to demonstrate all of the documentation and records of the home are up-to-date, in good order and that she is involved in monitoring these. The roles of the management and senior staff need to be more obviously defined to ensure there is clarity and clear lines of responsibility. The record keeping is not maintained to a good standard and is in need of reorganisation. The Registered Providers were recommended to change their systems. Making better use of the Schedules of the Care Home Regulations 2001, and National Minimum Standards, would assist them in providing evidence to the Commission for Social Care Inspection that all of the Regulations have been met. Better record keeping would provide ease of access for the staff team, particularly for new staff. The home has a relaxed atmosphere, and staff and service users were complimentary about the management of the home. It has been a requirement at the last two inspections that a quality assurance system must be in place. The Registered Provider said that he has commenced this work and, although evidence of some questionnaires to service users’ families were seen, limited consultation seems to have taken place with service users. The review of the quality of care is a longoutstanding requirement and the home must show how it intends to develop and improve the service, in consultation with the service users. The Registered Provider said that it is the policy of the home not to be involved with service users’ financial arrangements, apart from holding small sums of money for hairdressing, newspapers and other small items. Service users’ family and friends are involved in managing their money where service users cannot be responsible for their own. The Registered Provider confirmed that no valuables are held on behalf of service users at the present time. Each of the service users has, in their rooms, a locked drawer or a small, personal safe in which to store their personal items. The Registered Provider said that he is now carrying out the majority of the staff supervision sessions. Notes are made at each session, which are transferred to the computer and samples were seen. However, it was not evidenced that all staff have supervision regularly and it is recommended that Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 25 there is a spreadsheet maintained to evidence this. Consideration should also be given to staff being supervised by the Registered Manager and seniors who involved in the day-to-day running of the home, including the observation of staff’s care practice. Although there is a system to check areas of health and safety monthly, the records seen had not been fully completed. Much of the health and safety information was not easily to access and the Registered Providers need to have in place a system which shows the regularity of servicing and testing, which meets health and safety requirements. The records need to clearly demonstrate that the servicing and tests have been carried out, as necessary, with the dates recorded and information readily available. The Registered Provider has the equipment to carry out small electrical appliance testing. This was due to be carried out again. Legionella testing was carried out in June 2006. Fire alarms are checked weekly, and all of the points are covered regularly. The fire risk assessment was seen to have been completed but needs to be reviewed regularly. The fire records did not evidence that all of the staff had taken part in fire drills, on a regular basis, or in line with London Fire and Emergency Planning Authority guidance. The Registered Providers were advised to maintain a schedule in order to evidence this for inspections. As mentioned elsewhere in this report, devices are required to ensure that bedroom doors can be left open safely but close in the event of the fire alarm being activated. Water temperatures have been taken regularly, as required at last inspection, and all were seen to be within the safe range. Beech Haven DS0000027723.V300134.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 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X X 3 3 X 2 2 STAFFING Standard No Score 27 3 28 3 29 2 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.V300134.R01.S.doc Version 5.2 Page 27 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP1 Regulation 4 (1) Requirement The Statement of Purpose must be amended and produced in accordance with Schedule 1 of the Care Home Regulations 2001. The Registered Providers must provide all of the service users with the home’s terms and conditions, including the fees payable. 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. The risk assessments for service users must be completed and reviewed on a regular basis. (Previous timescales of 01/06/05 and 30/12/05 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 30/12/05 not met). The recording of the meals taken by individual service users must be recorded to provide evidence DS0000027723.V300134.R01.S.doc Timescale for action 31/10/06 2 OP2 5 (1)(b) 31/10/06 3 OP7 13(4),18(1) (c)(i) 31/10/06 4 OP7 13 (4) 31/10/06 5 OP8 12(1)(a) 13(1)(b) 31/10/06 6 OP15 16(2)(i) 17(2) 30/09/06 Beech Haven Version 5.2 Page 28 7 OP18 7 OP19 8 OP25 9 10 OP26 OP29 11 OP30 12 OP30 13 OP33 14 OP36 of a satisfactory diet, in accordance with Schedule 4 of the Care Home Regulations 2001. 18 (6) The Registered Providers must have in place the information to ensure that they are fully aware of the adult protection procedures and the management of adult protection issues. 23 (1)(a) An Action Plan is required to show (2)(b) when the refurbishment work, including the replacement of carpets and furniture, will commence. 23 (4)(c) (i) Where service users wish to keep their bedrooms doors open, suitable devices must be fitted to ensure that fire safety procedures are maintained and the doors are enabled to close when the fire alarm is activated. 13 (3),(4) Hygienic hand drying facilities (a)(c) must be in place to minimise the risk of infection. 19 (1)(a)(c) The documentation for recruitment must provide evidence that all of the information required to safeguard service users is in place. 18 (1)(c)(i) Evidence that all of the staff have the induction and training required, to meet the needs of the service users and for the safety of the home, must be provided. 18 (1)(c)(i) The training provided must be of suitable quality to demonstrate that all of the staff have the required knowledge and skills to carry out the work required, particularly in regard to first aid and fire training. 24 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 timescales of 01/08/05 01/03/06 not met) 18 (2) Staff supervision must take place DS0000027723.V300134.R01.S.doc 31/10/06 30/09/06 30/09/06 30/09/06 30/09/06 31/10/06 31/12/06 30/11/06 31/12/06 Page 29 Beech Haven Version 5.2 15 OP37 17(1)(2)(3) 16 OP38 23 (4)(e) on a regular basis and evidence made available to confirm this. Record keeping must be maintained in good order, to ensure that all of the records required under the Schedule 3 & 4 of the Care Home Regulations 2001 are available for inspection, and are up-to-date. Evidence must be available to demonstrate that all of the staff have taken part in regular fire drills and appropriate training. 31/10/06 31/10/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations It is strongly recommended that consideration is given to having care plans and associated information typed, rather than handwritten. This is to enable easier updating after reviews and to provide service users and their families with a copy, which would encourage their involvement. That to improve their knowledge of adult protection procedures, the Registered Providers attend training in the management of adult protection issues. That the safeguarding of adults and the adult protection procedures are regular items on the staff meetings agendas. It is recommended that a supervision schedule is maintained to evidence that all of the staff have received regular supervision. It is recommended that a system is introduced to maintain the records to comply with the Schedules of the Care Home Regulations 2001, to enable a more orderly system, and provide evidence that all of the Regulations have been met and for ease of access for the staff. It is recommended that a system is introduced which shows the regularity of servicing and testing of DS0000027723.V300134.R01.S.doc Version 5.2 Page 30 2 3 4 5 OP18 OP18 OP36 OP37 6 OP38 Beech Haven equipment. This needs to meet health and safety requirements, and demonstrate that all of the tests are up-to-date. Beech Haven DS0000027723.V300134.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection West London Area Office 11th Floor West Wing 26-28 Hammersmith Grove Hammersmith London W6 7SE 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 DS0000027723.V300134.R01.S.doc Version 5.2 Page 32 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!