Inspection on 08/08/05 for Beech Haven

This inspection was carried out on 8th August 2005.

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 26/01/06

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 Unannounced 08 August 2005 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 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 H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beech Haven Address 77 Burford Road, Chipping Norton, Oxfordshire, OX7 5EE Telephone number Fax number Email 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 - Mary Whitehead Provider/Manager 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 H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 03 March 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 H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on 8th August 2005. The purpose of the visit was to see how the home is meeting the National Minimum Standards. The visit involved speaking to residents to ascertain their views upon the care they receive at the home, staff members and the manager, viewing records held whilst also observing the day-to-day operations of the home. The home presented as one with a homely ‘family’ atmosphere, which was generally presented as clean, tidy and of very good décor. Residents were going about their daily activities in a calm relaxed atmosphere whilst staff were observed to provide care and support to the residents in a calm, unhurried manner and respecting their individuality, privacy and dignity at all times. Comments received from residents during the inspection included: ‘they are very good to me, they treat me very well’ ‘they are all very nice’ ‘it is good food, good quality food’ ‘I came and visited first and they were very explicit in information they gave me’ ‘they are all very kind here’ The inspector would like to thank the residents, staff and the owner for their warm welcome and their assistance during the inspection process. What the service does well: The home is maintained to a very high standard and provides a warm homely atmosphere. There are large accessible gardens to the rear of the property equipped with garden chairs and tables for residents’ and their visitors’ use during the warmer periods. Staff worked well as a team and were seen to be respectful and interacting with the residents in a manner that was thoughtful and considerate of their needs. Meals provided at the home are varied, well balanced, offer choice and are well presented. All residents spoken to were complimentary of the meals provided at Beech Haven. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 6 Regular meetings are held for residents in which they are able to openly discuss any concerns or compliments that they may have regarding the care and facilities provided at the home. These meetings are also a way in which the residents are able to keep updated on any issues regarding the home and to put forward any thoughts and ideas that they may have. What has improved since the last inspection? 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 H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 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 standard(s) 1, 3, 4 and 5 All prospective residents are provided with clear information about the home and its services, are invited to visit the home to meet fellow residents and members of staff and undergo an assessment of needs to ensure that both parties are satisfied that these needs can be met at Beech Haven. Service user involvement was not evidenced in all cases. EVIDENCE: The home’s Statement of Purpose and Service Users Guide provide detailed information about the home itself, and the services offered. Prospective residents and their families are invited to visit the home to gain a ‘feel’ of Beech Haven and to meet fellow residents and members of staff who will be providing the care, before making a decision about where to live. One resident spoke to the inspector stating ‘ I came and visited first and they were very explicit in the information they gave me’. All service users undergo a full assessment of needs before they are admitted to the home and both parties are assured that these needs will be met. One resident’s file failed to contain the signature of either the service user/representative to evidence they had been involved in the process and Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 9 furthermore it failed to contain the signature of the person who undertook the assessment and was further undated. A requirement has been made within this report to address this. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7, 8, 9 and 10 All residents’ needs are assessed, providing the basis for an individual plan of care, to ensure their health, personal and social care needs are met, although there was lack of evidence to show that the resident has played a part in the process. Staff treat the residents and their families in a sensitive manner, respecting their dignity and respect at all times. EVIDENCE: The inspector observed staff speaking to residents in an appropriate and kindly manner and noted that they always knocked upon doors before entering a person’s room. The staff were seen to treat the residents with the utmost dignity and respect. The inspector sampled three residents’ care plans during the course of the inspection and whilst these were comprehensive there were omissions present. One resident’s file informed the inspector that a care review had been undertaken, although this did not contain the signature of either the resident or their representative to evidence that they had in fact been involved in the Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 11 process. Furthermore, this review was undertaken in May 2005 and no further reviews since this date were evidenced to have taken place. Likewise, a further resident’s file informed the inspector that the review of care was last undertaken in June 2005. It is a good practice recommendation that residents’ care plans be reviewed at least once a month, updated to reflect any changing needs and actioned. One of the three resident’s files viewed failed to contain their photograph and a requirement has been made within this report to address this omission. The owner informed the inspector that photographs would be taken and that all care plans were in the process of being reviewed. Upon viewing the Controlled Drugs register, it was noted that the home follows good practice in gaining 2 signatures when controlled type drugs have been administered. It was noted that on two occasions this was not the case and only one signature was evident. Whilst the owner must be highly commended for following good practice with regard to controlled type drugs, it is acknowledged it is not a requirement but it is good practice that 2 persons sign on giving this type of drug to residents. Whilst the said drug was being maintained as a Controlled Drug, after discussing the above, the manager has decided to no longer record it under these conditions. It is recommended that this good practice should continue. It was further noted when touring the kitchen, that a Tupperware box was stored in the refrigerator for the purpose of drugs that need to be stored in a refrigerator. Whilst the kitchen is downstairs and inaccessible to residents, it is accessible to all staff and an unlocked refrigerator or Tupperware box are unsuitable methods for the safe storage of medicines. It is strongly recommended that the owner seeks a safe system for the storage of drugs that need cold storage to which only designated persons have access. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 12 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 standard(s) 12, 13 and 15 The home supports residents to maintain contact with their family and friends and the local community and are assisted to exercise choice over their day. There is a social activities programme offered to all residents. Residents enjoy wholesome meals, which can be taken in the home’s dining room or at a place of the resident’s choosing. Every effort is made to ensure that residents enjoy their meals. EVIDENCE: The home provides each resident with a monthly schedule of activities, which includes general exercises, bingo, scrabble, film shows, hand massage and manicures. A visiting mobile library, hairdresser and chiropodist visit the home for those who require their services, as does a minister who provides communion for those who wish to partake. The home welcomes all visitors and residents informed the inspector that they were welcome to visit at any time. The home arranges 2 parties during the year, one in December and one during the warmer summer months, to which family and friends are invited to join in the celebrations. The most recent being a Strawberry Tea held in the grounds of the home, which was well attended and enjoyed by all. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 13 Residents meetings are held quarterly, which keep the residents informed and involved in any issues regarding the home and allow the residents to voice any concerns and likewise, compliments, they may have. Residents are encouraged to join fellow residents and take their meals in the dining room if they so wish, or can take their meals in their own rooms if required. The inspector was informed that the lunchtime menu offers a choice of one hot dish and one cold dish followed by a dessert, although alternative meals can be provided upon request. Supper consists of soup, sandwiches or hot light snacks and a dessert. Hot and cold drinks are provided throughout the day and prior to the residents retiring for the night. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 14 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 standard(s) 16 ,17 and 18 There is a clear complaints procedure in place should a resident or their family members and friends need to access. All residents are given information on advocacy services available to them and if required, the owner and her staff will support residents to access the service. EVIDENCE: There is a complaints procedure should any residents have any concerns. Residents spoken to during the inspection confirmed that they would take any concerns to the owner if they had the need and felt that their concerns would be listened to and acted upon appropriately. Quarterly residents meetings are also a means in which any concerns may be voiced. The home has in place robust procedures in circumstances where there are any suspicions concerning possible abuse. Staff are all aware of the procedures and have attended training on the protection of vulnerable adults and are clear on the procedures to follow. The home facilitates access to advocacy services and takes steps to ensure that residents are enabled to take part in the local and national elections if they require. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 15 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 standard(s) 19,20,21,23,24 and 26 Overall residents live in a comfortable, well maintained environment with their personal possessions around them, and have safe access to all parts of the home and grounds; however, the carpet in front of the downstairs fire escape was in a bad state of repair and needed attention during the inspection, as this was a potential risk to residents and staff. Residents have personalised bedrooms and have the use of suitable toilet and washing facilities. EVIDENCE: Overall the home presented as clean, orderly and well maintained. All bedrooms have a washbasin, eight rooms have ensuite facilities and the home has three assisted baths and separate WC facilities. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 16 Bedrooms viewed on the day were individually styled with residents’ personal possessions and were pleasantly decorated and homely. However, the carpet in one of the resident’s bedrooms presented as odorous. After discussion, it was agreed that the bedroom carpet would be deep cleaned the following day. A further carpet in front of the fire escape was frayed and worn, which the inspector pointed out to be a potential risk to residents and staff. The owner immediately addressed the issue making it safe, temporarily, until the following day where it was agreed by the owner that it would then be rectified permanently. There is a large garden at the rear of the property which residents, their families and friends regularly use during the warmer periods and is equipped with handrails, ramps, tables and chairs thereby making it accessible to all. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 17 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28 and 29 The home is staffed in accordance with the needs of the residents and the staff undergo the appropriate training to meet the overall needs of all residents. EVIDENCE: The inspector was informed that the home’s comprehensive recruitment procedures ensure as far as is possible that residents are in safe hands. All new staff undergo an induction training in order to give them the skills necessary for caring for the residents’ needs. This is followed by further training in any areas relating to the needs of the residents who are in their care. The inspector viewed 3 staff members’ files that were chosen randomly. Whilst discrepancies were found in the recruitment procedure of one, in which no references were held on file, it was acknowledged that recruitment was undertaken by the previous owner and was of no fault of the present owner. A recently appointed member of staffs’ file was viewed and evidenced that a comprehensive recruitment procedure had been followed and all relevant pre employment checks had been undertaken. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,33,35 and 38 The home is very well managed and is run in the best interests of those they care for. EVIDENCE: The owner has many years of experience and has been registered with the Commission for some years, regularly updates her knowledge and skills and addresses any requirements made by CSCI immediately, deeming her a responsible fit person to manage and run the care home. The home does not undertake any financial roles on behalf of the residents, but directs residents to an advocacy service to undertake this role if there are no family members or the resident would prefer an independent person with no vested interests. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 19 The home works to ensure the health, welfare and safety of both the residents and staff are promoted and protected and the issue of the carpet in front of the fire exit, as discussed in the section headed ‘Environment’, was dealt with immediately to ensure this. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 20 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 x 2 3 3 x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 2 3 x 3 3 x 2 STAFFING Standard No Score 27 3 28 3 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 x 3 x 3 x x 3 Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 21 Are there any outstanding requirements from the last inspection? 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 OP3 Regulation 14 Requirement The registered person must ensure assessment of needs and reviews of care are dated and gain the service users/advocate signature to evidence their part in the process and contain the signature of the assessor. A photograph of each service user must be kept on file. The carpet in front of the fire escape must be made permanently safe to protect the health and safety of service users and staff. Timescale for action 8th August 2005 2. 3. OP7 OP19 17(1a) Sch 3 13(4a) 8th August 2005 9th August 2005 4. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard OP9 OP9 Good Practice Recommendations It is reccommended that the good practice being undertaken with regard to the recording of administration of controlled type drugs be continued. It is strongly reccommended that a safe system for the storage of drugs which need cold storage be sought. One to which only designated persons have access. H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 22 Beech Haven 3. 4. OP26 OP7 It is strongly reccommended that where spillages occur, these be cleared up so as to ensure all areas of the home are free from offensive odours. It is reccommended that residents care plans be reviewed at least once a month, updated to reflect any changing needs and actioned. Beech Haven H57-H08 S13064 Beech Haven V242954 080805 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Burgner House, 4630 Kingsgate, Cascade Way, Oxford Business Park South, Cowley, Oxford. 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