Inspection on 20/12/05 for Beech Hill Grange Limited

This inspection was carried out on 20th December 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 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 Hill Grange Limited 24/05/07

Beech Hill Grange Limited 04/09/06

Beech Hill Grange Limited 03/08/05

Beech Hill Grange Limited 15/02/05

Beech Hill Grange Limited 09/09/04

Beech Hill Grange Limited 27/01/04

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Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Beech Hill Grange Limited 1 Beech Hill Road Wylde Green Sutton Coldfield West Midlands B72 1DU Lead Inspector Kath Strong Unannounced Inspection 20th December 2005 10:00 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 Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Beech Hill Grange Limited Address 1 Beech Hill Road Wylde Green Sutton Coldfield West Midlands B72 1DU 0121 373 0200 0121 384 7500 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) Mrs Judith E Middleton Ms Joy Margaret Lavender Care Home 36 Category(ies) of Dementia - over 65 years of age (36), Old age, registration, with number not falling within any other category (36), of places Terminally ill over 65 years of age (36) Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the manager successfully completes the Registered Managers Award (NVQ Level 4 in Care Management) or equivalent by April 2005 3rd August 2005 Date of last inspection Brief Description of the Service: Beech Hill Grange is situated within Wylde Green with good access to nearby Sutton Coldfield and Birmingham city centre. There are bus routes in close proximity and off road parking at the front of the premises to accommodate ten vehicles. The premises consist of a converted and sympathetically extended residential property. The building blends well with the other residential properties that are directly adjacent. The home has recently been extended to increase the communal areas. The ground floor has two lounges, and the dining room consists of the recently re-built conservatory. There is a rear garden, which includes a raised paved area with seating areas and is accessed by the conservatory. Bedrooms are located on the ground and first floors consisting of single and some shared rooms, those added at a later date have en-suite facilities. There are communal toilets and limited assisted bathing facilities. The kitchen and laundry services are provided on site. Beech Hill Grange provides personal and nursing care for up to 36 persons of both gender aged 65 years or above. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to carry out an unannounced inspection and to review the progress made on the requirements generated at the last inspection. The registered manager has recently left the home and the deputy is currently acting manager, she was not available during the visit. In depth discussions were held with the registered provider, the administrator and the senior carer. Individual discussions took place with the registered nurse, six residents and a relative. The system of administering medications was observed and relevant documentation reviewed. Four care plans were examined one of which included case tracking in order to ensure that all identified needs were being met. At the conclusion verbal feedback was provided to the registered provider. Both inspections for the year were unannounced. The rationale for this being that historically the home has made steady progress in addressing the requirements raised. What the service does well: What has improved since the last inspection? The building works to increase the size of the conservatory have been completed. The room includes new dining and recreational furniture. Twelve bedrooms have had new carpets and curtains. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 6 The laminate flooring has been completed in communal rooms with carpet remaining in the centre of the first lounge and throughout the reception areas. The kitchen has been refurbished including new flooring and oven resulting in an improved and more spacious layout. A number of hospital beds have been purchased; the majority of the home now has hospital beds. The administrator has a good knowledge of all residents and makes herself available each afternoon to talk to residents. The services of agency staff are infrequently utilised. 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 Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 5 An open door approach is adopted for prospective residents to view the home. EVIDENCE: Relatives and prospective residents are encouraged to visit the home; they are given a full conducted tour and are welcome to make further visits. They are facilitated in talking to other residents and staff. The prospective resident is invited to remain at the home for part of a day to observe the day to day operations and to sample the food provided. Standards 1, 2, 3, and 4 were examined at the last inspection and were fully met. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Resident’s health and personal care needs are clearly defined and regularly reviewed but risk assessments were found to be out of date. There is a proactive approach to the utilisation of external professionals. The system for administration of medications is safe. Residents are treated with respect and their privacy and dignity are respected. EVIDENCE: Care plans continue to be comprehensive, they include the identified needs and how these will be addressed. Files include life histories, dietary requirements and preferred routines of daily living and recreational activities. Monthly and formal six monthly reviews are carried out with the resident and their relatives being invited to participate. Both trained and care staff maintains the records. Risk assessments were found to be out of date and a recent incident reported to CSCI indicated the urgent need for review. A relative who visits the home daily said, “Standards are fantastic, staff are very kind”. Two residents commented, “Staff look after me to the best of their ability”, “A good crowd, staff respond well if I press the buzzer”. Files included details of the services Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 10 provided by external professionals the rationale and outcome of visits were clearly documented. Since the last inspection the policy for the administration of medications has been rewritten and found to be satisfactory. Observations of the administration of medications and the documentation were found to be adequate. The privacy and dignity or residents appeared to be promoted and respected by staff. The comments received from residents did not raise areas of concern. Standard 5 was examined at the last inspection and was fully met. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 Meals provided are good offering both choice and variety as well as catering for special dietary needs. EVIDENCE: Standards 12, 13, 14 and 15 were examined at the last inspection and were fully met. Positive comments were received from residents regarding the menu and meals provided. The new dining room provides improved facilities and space for access of wheelchair users. The presentation of lunch was noted to be satisfactory and staff provided discreet assistance. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 The arrangements for the protection of residents are robust in protecting them from harm or abuse. EVIDENCE: The written policy in respect of adult protection was found to be satisfactory at the last inspection. Two previous incidences determined that staff respond appropriately to issues of concern. The majority of staff have completed training in this aspect of care and training has been arranged for the four remaining staff. Standard 16 was examined at the last inspection and was fully met. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24, 25 and 26 Residents live in a safe, warm, comfortable and well maintained environment. Corridors are narrow and there is limited storage space. There continues to be insufficient bathing and sluicing facilities within the home. EVIDENCE: The accommodation provided is homely and well decorated. There is a maintenance programme in place and a long term strategy, which are regularly reviewed. Corridors are narrow for wheelchair access and there is an obvious lack of storage facilities. In order to ensure privacy confidential meetings are now carried out in the staff room. The communal space has recently been extended. Residents now have a choice of two adjoining lounges and meals are taken in two sittings in the conservatory/dining room. The rear paved area includes seating areas and leads onto an attractive lower garden, which residents can frequent. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 14 The lack of adequate bathing facilities remains an area of concern. There are plans to convert the treatment room situated on the first floor into an assisted bathroom and to install an assisted shower room on the ground floor. The registered provider stated that he anticipated that the work should be completed by July 2006. There are 20 single rooms 11 of which have en-suite facilities and 8 shared rooms. All rooms are well appointed and furnished to the required standard. They are personalised to the extent preferred by the occupant, items of personal furniture were in evidence. The programme of installing suited room locks has not been completed and now remains outstanding from three previous inspections. The home was found to be safe, warm and hygienic throughout. Odour control is well managed. Although commodes are cleaned daily the home must install appropriate sluicing facilities, which has been outstanding for the last two inspections. The registered provider advised that he anticipated completion of the works by April 2006. Standard 22 was examined at the last inspection and was fully met. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 15 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 and 29 The staffing levels are inadequate to meet resident’s needs. Staff who have been employed for an extensive period of time have not had complete preemployment checks carried out. EVIDENCE: Due to the recent departure of a senior nurse the home was not operating to the full required trained staff complement. During this period the inspector was advised that the senior carer who has in depth knowledge and experience was working along side the acting manager and other trained staff. Positive action was being taken to fill the vacancy and another senior nurse is due to commence employment early 2006. The home must work towards having two trained staff on duty each weekday with the manager having adequate supernumery time allocated. Although all recently employed staff have had full pre-employment checks carried out this is not the case for staff who have been in post for some considerable time. The home must ensure that two written references are obtained for all staff working within the home. Standards 28 and 30 were examined at the last inspection and were fully met. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 16 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, 37 and 38 The registered provider has a clear plan and long term strategy for the development of the home. The quality assurance system is being developed but is not completed. All aspects of safety have been ensured. EVIDENCE: The registered manager has recently resigned from her post. In the meantime the deputy has taken on the role of acting manager. Following a review of the management structure, two senior registered nurses will replace the current deputy role. One vacancy should be filled by early 2006 and the other post awaits a suitable applicant. The home has appointed a quality consultancy that has carried out initial staff training. The home is currently reviewing all written policies and procedures prior to moving on to the next objective. The registered provider advised that the quality assurance system was being gradually developed and implemented. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 17 The arrangements for the safe keeping and handling of residents personal monies was found to be satisfactory. Resident’s records are stored securely whilst permitting staff access at all times. All required servicing and checks of equipment were being carried out on a timely basis. The maintenance operative continued to carry out and document random checks on hot water outlets that residents have access to. Fire alarm and emergency lighting checks were being carried out including fire drills and regular staff training. Standard 36 was examined at the last inspection and was fully met. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 3 3 1 X X 2 3 2 STAFFING Standard No Score 27 2 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X 3 3 Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 19 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 OP7 Regulation 13(6) Requirement All residents risk assessments must be regularly updated and reviewed when circumstances change. The registered person must ensure that adequate assisted bathing facilities are provided as identified by the dependency levels of residents. N.B. This remains outstanding from two previous inspections. The registered person must complete the commenced works to fit all bedroom doors with suited locks. The registered person must purchase and install a sluicing machine that complies with requirements regarding infection control. N.B. This remains outstanding from two previous inspections. The registered person must provide two nurses during the daytime (7 hours) every weekday. All staff employed must have two satisfactory written references in place. DS0000024822.V274181.R01.S.doc Timescale for action 15/02/06 2. OP20 23 (2)j 31/07/06 3. OP24 12(4)a 31/05/06 4. OP26 23(2)k 30/04/06 5. OP27 18(1)a 31/01/06 6. OP29 19(1)b Schedule 2 31/03/06 Beech Hill Grange Limited Version 5.1 Page 20 7. OP33 24(1-3) The registered person must complete the development and implementation of a quality assurance system that incorporates resident’s views. N.B. This remains outstanding from two previous inspections. 31/03/06 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 OP19 Good Practice Recommendations The registered person must give consideration to the lack of storage space for equipment. Beech Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Hill Grange Limited DS0000024822.V274181.R01.S.doc Version 5.1 Page 22 - 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. 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