Inspection on 09/05/07 for Beech Haven

This inspection was carried out on 9th May 2007.

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 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 17/01/07

Beech Haven 29/08/06

Beech Haven 15/11/05

Beech Haven 10/05/05

Beech Haven 17/08/04

Beech Haven 26/04/04

Beech Haven 08/09/03

Similar services:

Ashlong House

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

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

CARE HOMES FOR OLDER PEOPLE Beech Haven 15-19 Gordon Road Ealing London W5 2AD Lead Inspector Ms Jane Collisson Key Unannounced Inspection 9th May 2007 10:15 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.V337096.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.V337096.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.V337096.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. One named service user with Dementia can be accommodated, as agreed by the Commission for Social Care Inspection, on 19th January 2006. The service user may remain resident until such time when the home is unable to meet the individual service users assessed needs and care plan and for as long as there is no deterioration which affects the well being of other service users. The home must advise CSCI when the service user no longer resides at the home. 17th January 2007 Date of last inspection Brief Description of the Service: Beech Haven is a private care home for thirty older people. It was first registered in 1986 under the Registered Homes Act 1984. The Registered Providers are Mr and Mrs Scarman and Mrs Scarman is the Registered Manager. Currently the home is registered for older people only, including those with physical disabilities. There is one variation to the categories of registration for a person who has dementia. The home is three large attached houses, in a residential area near to Ealing Broadway. The home has easy access to shopping facilities and local amenities, including places of worship. An underground and main line station and several bus routes are close by, and the North Circular Road and A40 are within a few minutes’ drive. The accommodation consists of thirty single bedrooms, which are on three floors. There is a large lounge/dining room that is equipped to comfortably accommodate everyone for their meals. The lounge overlooks an attractive enclosed garden to the rear of the home. The main kitchen is off the dining room. There is a small lounge situated at the entrance of the home. This can be used as a quiet area, to see visitors or for meetings. There are adequate bathroom and toilet facilities on each floor. A passenger lift is provided and there are ramps to access the home and garden. To the front of the home there are parking spaces for several cars. The fees for the home are from £460 to £530 weekly. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out on the 9th May 2007 from 10.15am to 4.30pm. One of the Registered Providers was in the home but the Registered Provider/Manager was on leave. There were fifteen people resident in the home, fourteen of whom were met during the course of the inspection, and there were fifteen vacancies. Although the Registered Providers did not pursue their application for part of the home to be registered for people with dementia, the home does have residents with this diagnosis. The Statement of Purpose has not yet been amended to show how the home is meeting their needs. The majority of people living in the home were seen in the main lounge/dining room, but those who are able to choose confirmed that they spend their time as they wish. One person chooses to stay in their room for the majority of the time and this choice is respected. The second, smaller lounge was not seen to be used on this occasion but is available for visitors, meetings or as a quiet room. The dining area is used for some activities and a small group of people participated in a craft activity in the afternoon. A religious service had been held during the morning. People also have their religious and cultural needs met by having access to their places of worship and having their dietary needs catered for. A tour of the home took place and the majority of the communal spaces, and some of the private spaces, were seen. Some redecoration of the bedrooms has taken place, but the outstanding work in the communal areas, including the replacement of the carpets on the stairs and in the hallway, had not commenced. Five staff were in the home during the morning, including the cook and maintenance person, who also works as a support worker. Another member of staff was supporting people with activities. The staff who were spoken to were positive about working in the home. One visitor was met during this inspection and another was arriving as the Inspector was leaving. All of the people spoken to during the course of the inspection were positive about the home and the staff. There was a relaxed atmosphere, with good interaction noted between the staff and the people using the service. At the inspection in January 2007, there were fourteen requirements made. Twelve were fully met and two have been repeated in full. Some have been partially repeated in the ten requirements made at this inspection. Information on these is included in the section on “what they could do better”. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? What they could do better: The Statement of Purpose is required to be revised to demonstrate how the needs of people with dementia currently living in the home are being met by the staffing levels, training, activities and the home’s environment. Staff must have the opportunity to undertake the training to work with people with dementia, or other special needs, in order to provide a good quality of care and support and to develop their skills. The risk assessments for manual handling, self-medication, and bed sides must be fully completed to show how the risks can be minimised. Where risk reduction plans are in place for people who self-medicate, the Registered Providers need to ensure that the requirements such as safe storage, which minimise the risks to all of the people in the home, are followed. The Registered Providers must ensure that, where refurbishment is planned, and timescales agreed, the work is carried out. This is of particular importance where the people living in the home may be put at risk by worn carpets on the stairs. The recruitment records for a new member of staff were not available. To maintain confidentiality, the safe storage of records is required and the information to show that good recruitment practices have been followed must be available for inspection. While the majority of staff have been trained in the basic courses by the Registered Provider, all staff need to be up-to-date with these. Staff who cook for the residents must have up-to-date food hygiene training. Those cooking on a regular basis, and responsible for menus, should also have training in nutrition. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 7 The review of the quality of care has been outstanding for some time. Although there is some evidence that people using the service are now being consulted, the Registered Providers need to provide evidence that the quality of care has been assessed, in ways which involve those who live in the home, and there is a development plan to show how the improvements will be made. Regular supervision, on a one-to-one basis, has commenced but this has not been extended to all of the staff team. All staff should have the opportunity to meet regularly with their line manager to discuss their support, development and their care of the people living in the home. It is an outstanding requirement that the fire risk assessment is updated in accordance with new legislation. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Beech Haven DS0000027723.V337096.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.V337096.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 (Standard 6 was not assessed as there is no Intermediate Care unit) Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current Statement of Purpose and Service Users Guide do not reflect fully the needs of the people who use the service. The information to demonstrate that the home is suitable to meet the needs of the people with dementia is not detailed in the Statement of Purpose. People have the opportunity to visit the home prior to admission and the assessment procedures are satisfactory. EVIDENCE: As previously required, the Registered Providers had amended the documentation that people require to support them to make a decision about moving to the home and copies have been placed in the bedrooms. The Registered Providers did not proceed with the application to register part of the premises for people with dementia. However, as there are a number of people in the home who have this diagnosis, the Statement of Purpose needs to be amended to show that their needs can be met by the environment, staffing levels, staff training, professional support and the activities which are Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 10 provided. Not all of the staff team have been trained to work with people with dementia. As this is one of the skills needed to support some of the people in the home, this should be undertaken as soon as possible. The admission procedures are in place and, in the two files examined, the Registered Manager had, in addition to receiving needs led assessments from the local authorities, carried out her own assessments prior to admission. The contracts/terms and conditions have been provided to the people using the service and were seen to be signed. The home does not have Intermediate Care unit and so this key standard is not assessed. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Some improvements have been made to the care planning processes, particularly in regard to health recording. However, involving the people using the service and their representatives in the process of care planning would be greatly enhanced by having the plans in an accessible format. This would support the home to use a more “person centred” approach. The risk assessments, particularly for manual handling, bedsides and self-medication, are insufficient to show that all of the needs have been taken into consideration to minimise risks. The medication procedures have been improved to minimise the risk of errors. EVIDENCE: Efforts have been made to improve the care plans but some issues remain with regard to accessibility and involvement of the people using the service. A new style of care plan had just been introduced at the last inspection which had focussed on providing more individual information about the person and how they wished their support to be provided. This has not been extended for the majority of the people using the service. The proposal to type the care plans Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 12 has not continued. The majority of the care plans are handwritten and, in some cases, the problems with legibility still remain. One family member was seen to be involved in providing a dietary plan where cultural needs were required to be met. Providing copies of the current care plans to the people using the service, and their representatives, would not support them to fully understand or agree the plans. This was discussed with the Registered Provider who agreed that, to have them typed on the computer would improve access for both staff and residents. This would also provide much easier updating when reviews are carried out. He undertook to have this work carried out. Four of the care plans were examined. While the information on the support needs was generally satisfactory, the risk assessments still require more detail. Five people in the home are currently transferred using hoists. The risk assessments for moving and handling need to be improved, to show that the information on weight, height and skin integrity have been taken into consideration. Where bed sides are in use, the reasons need to be detailed as to why these are being used and whether all of the possible risks have been considered. As the use of bed sides is restrictive for the person to whom they are supplied, their use needs to have been seen to be agreed. The health needs of the people using the service are recorded in the care plans and a clearer system of recording has been introduced. Medical professionals still make notes in the files of the people they visit but a record of the outcome of visits is now recorded separately to help with continuity and ease of access. Since the last inspection, when a requirement was made with regard to monitoring of the medication procedures, the Registered Manager has put in place a system for ensuring that the stock of non-dosetted medication, such as antibiotics, can be checked on a daily basis. The medication was examined and found to be in order. The Registered Provider said that a visit from the pharmacy was due the following week. A risk assessment for a person who is self-medicating was not sufficiently detailed and, although the plan indicated that the medication would be stored securely, this was not being carried out. The Registered Provider undertook to improve this situation. All of the people spoken to on this inspection were satisfied with the care and support offered by the staff and the way in which they are treated. Personal care is provided to suit the needs of the residents and it was confirmed that same gender care is provided for dignity and privacy. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Providers are looking at ways to provide a wider range of activities to suit the needs of the people using the service. Staff are being encouraged to use their individual expertise to undertake activities. The provision of large print notices could help to support people to be aware of the activities and meals offered. EVIDENCE: It was required at the previous inspection that a programme of activities should be provided, in consultation with the people living in the home. Although activities were not being advertised, one member of staff was carrying out a craft session with a small group of the more able people during the afternoon. He was due to attend a training course for reminiscence shortly after the inspection. Three of the people were enjoying reading their books and newspapers. One person enjoys watercolour painting and is able to carry out this pastime, showing examples of the paintings to the Inspector. Communion is brought to the home for those people who wish to participate, and a service was held on the morning of the inspection. Although only one person is able to access the shopping area of Ealing Broadway unaccompanied, Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 14 it is close by and provides a range of amenities, including shops, cafes and a library for those able to go out with family, friends and with staff. One person went out to lunch with a family member and other people confirmed that their visitors are welcomed to the home. The Registered Provider said that new activities were being tried to suit individual people’s needs. He had held a meeting with the more able residents to ascertain their views. He was also trying to introduce card games, such as bridge, and had introduced a shove-halfpenny board, which one person was enjoying. He said that staff would be encouraged to use their individual skills to specialise in carrying out a particular activity, such as nail care. Suitable activities for people with dementia were less evident and those which provide stimulation and interest, to suit each individual person’s needs, should be considered. There was some concern expressed by a small number of residents that there can be limited opportunities for interaction when there are people who cannot converse because of their dementia. The Registered Provider is aware of the need to demonstrate, in the Statement of Purpose, how the needs of all the people residing in the home, and prospective residents who have specialist needs, are to be met. It is recommended that the Providers look at the ways in which the communal facilities, including the second lounge and dining area, might be better used to promote conversation for those people who would enjoy this. People confirmed that they were able to have their religious needs met by continuing to visit their places of worship and by having communion within the home. One volunteer visits weekly to undertake activities, such as cards or games, with those who enjoy them. During the inspection, the lunchtime meal of beef casserole or chicken pie, with mashed potatoes and mixed vegetables, was served. The dessert was a choice of individual apple pies and custard, or rice pudding. The people spoken to were generally complimentary about the meals but were not aware of what was being served. It is again recommended that the menus are displayed, in formats which people living in the home will be able to access. The Registered Provider said that having pictures of the meals was being considered. One person had a preference for the evening meals, when dishes such as ravioli and macaroni cheese are served. It is recommended that further consultation is carried out to ascertain if other people would prefer a wider variety for the lunch time meals and whether the person could be offered these meals at lunch time. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The Registered Providers have provided people who use the service, and their representatives, with information on raising complaints and concerns and are new ways of helping people to express their views are being introduced. The more able residents felt confident about raising concerns. Staff training on safeguarding adults training needs to be extended to all staff to ensure that they have the good knowledge of the procedures. EVIDENCE: There have been no recorded complaints since the last inspection in January 2007. In the care plans examined, it was noted that the complaints and adult protection procedures have been discussed with the people using the service and their representatives. People have been provided with copies of the Service Users Guide in their bedrooms, which includes the complaints procedure. The Registered Providers had just started a system of having space in each person’s file to record any comments, which may be concerns or compliments, they may have about the meals, activities or other services. There have been no safeguarding adults issues raised in the home but, from the training records provided, five staff have not had this training. The Registered Provider said that he was in the process of trying to get an external trainer for this course. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 16 The Registered Provider said that none of the people using the service have their money managed by the home and, when any expenditure is incurred on their behalf, he invoices the person or their representatives. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 23, 24, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There has been limited progress on the environmental improvements that were required to the halls and stairs, particularly in relation to the replacement of the carpets. Although most areas are spacious and comfortable, the bathrooms would benefit from being made more homely. EVIDENCE: Although some of the bedrooms have been decorated, no further work has been carried out in the communal areas. This was due to be completed in April 2007. The Registered Provider said that the work would be commencing shortly and will include the painting of the hallways and the replacement of the carpets. There are areas of carpet which are worn and these need to be replaced before they become a possible trip hazard. The home’s garden is pleasant and accessible. Although not being used on this visit, a number of people said that they enjoy the garden in good weather. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 18 The Registered Provider said that plans to change the home to better suit people with dementia were still under consideration. The current layout of the home, which is large and has a number of corridors and staircases, would not safely accommodate people with dementia who wander. The Registered Providers have shown an awareness of the need to provide a more suitable environment to support those people with dementia who are fully mobile. The majority of the bedrooms in the home are of a good size, with many over 13 sq. metres. Those seen were comfortable and have been personalised to suit the people who use them. There are sufficient bathrooms for the use of the current service users and bath hoists are available. Whilst the bathrooms were seen to be clean and serviceable, these could be made more pleasant to use by the addition of brighter furnishings and accessories and it is recommended that this is considered. The Registered Provider said that two staff are always involved when people are being transferred by hoist. This was observed during the inspection. Five of the people using the service currently require this assistance and staff are trained by the Registered Provider. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has not yet met the target of having 50 of the staff team trained to National Vocational Qualifications Level 2 or above. The majority of staff have the basic training they require but some are in need of more specialist training to fully meet the needs of the people now in the home. The lack of any information regarding a new staff member did not evidence that the required information was being obtained or stored appropriately. There is a low turnover of staff, which provides consistency. EVIDENCE: The Registered Provider made available a matrix showing the staff training that has been carried out. The Registered Provider, using videos and workbooks, undertakes the majority of training and has attended “training for trainers” courses in order to provide this. The information showed that, while the majority of the staff have the training in the necessary basic courses, there were a number of gaps. A group of eight staff were in the process of undertaking the food hygiene training, required at the previous inspection, using workbooks. This includes a test, which is certified by the company who provide the training pack. However, the person carrying out the majority of the cooking was not participating in this training and had not undertaken food hygiene training for five years. Staff who are responsible for the meal provision must be sufficiently trained and undergo the required refresher courses to keep their training up-to-date. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 20 In addition to taking the training course as soon as possible, it is strongly recommended that advanced training in undertaken in food hygiene and nutrition by those responsible for providing the meals. Sufficient staff were in the home to provide support for the fifteen people resident. Three care staff, including the one who was cooking the lunch time meal, were on duty. In addition, two staff had been involved in providing personal care support earlier in the day and were carrying out other duties, such as maintenance work and activities. The Proprietor’s son works in the home and has been concentrating on providing activities and training. He was also supporting the staff to undertake the food hygiene course. The Provider said that there are no staff vacancies and more than sufficient staff are employed to provide cover for the number of people currently in the home. Five of the staff team of sixteen have achieved National Vocational Qualifications at Level 2 or above and two are currently undertaking this. One person with the qualification was due to go on maternity leave. An Action Plan is required to show how the home will achieve the target of having 50 of the staff trained. A new induction procedure, which meets the Skills for Care Common Induction Standards has been introduced. The Registered Provider is using this as a training tool for staff already in post to evidence good practice. One staff had been recruited since the last inspection but the file could not be found and it could not be ascertained if the information required for the person to commence work had been obtained. A sample of the files of five of the longer serving staff members were examined and found to be in order. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management systems are improving, with better monitoring procedures in evidence. Regular reviews of the quality of care, involving the residents and their representatives, would help to demonstrate that the service is being developed in accordance with the wishes of the people using the service. Most staff have been offered support through regular supervision sessions but this needs to be extended to all of the staff team to aid consistency and development. EVIDENCE: The Registered Provider/Manager, who was on leave during this inspection, manages the home. The other Registered Provider is in the home on a daily basis and is responsible for training staff and for much of the documentation. Both have managed the home for many years and have undertaken the Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 22 Registered Managers Award. Their son is also involved in training, activities and support work. Many of the staff have been in the home for some years and no agency staff are used. Any additional work is undertaken from the bank of staff the home employs. The home has an informal, relaxed atmosphere and a good rapport was noted between the staff and the people using the service. The Registered Provider said that the requirement for a review of the quality of care had not been completed. A survey was undertaken about the food and copies were seen in the files examined. A system of recording individual comments had just commenced. These, and other quality assurance and monitoring systems, have not been developed into a quality review and this is still an outstanding requirement. As mentioned elsewhere in this report, the home does not have responsibility for the finances of the people living in the home and these are managed by the person or their representative. There have been improvements in the general record keeping, including the monitoring of supervision and other management tasks. Because the home is managed by the Providers, Regulation 26 monthly visits are not required. However, the owners have put in place reporting systems, by the senior staff, to ensure that delegated tasks are carried out. Regular supervision, on a one-to-one basis, has been undertaken with the majority of the staff team and records maintained of the sessions. However, five of the staff had not had a session recorded in the last six months and this needs to be rectified to ensure that all of the team are offered this support. There were no health and safety concerns noted at this inspection with the exception of the possible hazard of the worn carpet on the stairs. Although this work had been planned to take place some time ago, it has not been undertaken and needs to be carried out as soon as possible to ensure the safety of anyone using the stairs. The fire risk assessment is required to be updated in the light of the new legislation, which came into effect in October 2006. This was required at the last inspection. The Registered Provider said that he would now undertake this. Records of the fire drills attended by staff demonstrated that the majority had attended between two and four drills in the 2006/7 and five staff had each attended one drill. The equipment used for hoisting people, including the bathing equipment, had been serviced in March 2007. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 2 X N/A 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 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X 3 3 3 3 X 3 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 3 2 X 3 2 X 2 Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 24 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 Timescale for action 30/06/07 2 OP4 12 (1) 18 (1)(c)(i) 3 OP7 13(4),18 (1) (c)(i) 4 OP9 13 (4) The Registered Providers must ensure that the Statement of Purpose is revised to demonstrate how the needs of people with dementia currently living in the home are being met by the staffing levels, training, activities and the home’s environment. The Registered Providers must 31/07/07 provide the training to all staff to provide and develop the support for people who have specialist needs, including those with dementia. The Registered Manager must 30/06/07 ensure that the risk assessments undertaken for manual handling, self-medication, and bed sides are fully completed to show how the risks can be minimised. The Registered Manager must 30/06/07 ensure that, where people are deemed to be able to selfmedicate, that the risks to the person, and to other people living in the home, are minimised by the risk assessment being followed. DS0000027723.V337096.R01.S.doc Version 5.2 Beech Haven Page 25 5 OP19 23 (2) (b) 6 OP29 7 OP30 8 OP33 9 OP36 10 OP38 The Registered Providers must ensure that where refurbishment is planned, and timescales agreed, the work is carried out. This is in relation to the new hall and stair carpets. (Timescale of April 2007 not met). 17 (1)(b), The Registered Manager must (2) Sch. 4 ensure that the recruitment (6) records for all staff are securely stored and available for inspection to evidence robust recruitment procedures. 18 The Registered Providers must (1)(c)(i) ensure that staff are shown to have undertaken all of the basic training courses, including food hygiene, which are relevant to the work they perform. 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 30/11/06 and 31/05/07 not met). 18 (2) The Registered Manager must ensure that all staff receive regular supervision, on a one-toone basis, for their support and development. 23 (4a)(b) A fire risk assessment must be completed in accordance with the new legislation. (Previous timescale of 31/03/07 not met). 31/07/07 30/06/07 31/07/07 31/07/07 31/07/07 31/07/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP12 Good Practice Recommendations That, to encourage the service users to participate in a DS0000027723.V337096.R01.S.doc Version 5.2 Page 26 Beech Haven 2 3 4 OP15 OP15 OP19 5 6 OP19 OP30 structured programme of group or individual activities, these are advertised with a large print newsletter, or on a prominently displayed notice board. That a more visible menu, either on a board, or placed on the tables, is available so that those service users who are able to do so can be supported to choose more easily. That further consultation is carried out to ascertain if people would prefer a wider variety of meals at lunchtime. That the Registered Providers look at the ways in which the communal facilities, including the second lounge and dining area, might be used to provide a wider variety of environments for people to use. That the bathrooms are made more pleasant to use by the addition of brighter furnishings and accessories. That the staff who are involved in cooking the meals are provided with training in advanced food hygiene and nutrition. Beech Haven DS0000027723.V337096.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection West London Local Office 11th Floor, West Wing 26-28 Hammersmith Grove London W6 7SE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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