Inspection on 24/05/07 for Beech Hill Grange Limited

This inspection was carried out on 24th May 2007.

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

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

Other inspections for this house

Beech Hill Grange Limited 04/09/06

Beech Hill Grange Limited 20/12/05

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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Maple Lodge

Heathlands

Aston Court Nursing Home

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Ravenhurst

Bank House

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 Key Unannounced Inspection 24th May 2007 09:10 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.V337905.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 Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 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 vacant post 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.V337905.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. That the manager successfully completes the Registered Managers Award (NVQ Level 4 in Care Management) or equivalent by April 2005 That one named person under 65 years of age at the time of admission can continue to be accommodated and cared for in this Home. 4th September 2006 Date of last inspection Brief Description of the Service: Beech Hill Grange provides accommodation and nursing care to thirty-six residents. The home is situated in 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 and blends well with the other residential properties in the area. The home has recently been extended to increase the communal areas and the new conservatory accommodates the dining room. The ground floor also has two lounges and the garden can be accessed from 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. Communal toilets and limited assisted bathing facilities are available on each floor and a call bell system is available in all areas. Kitchen and laundry services are provided on site. All areas of the home can be accessed by a passenger lift and there is a range of equipment to assist residents with mobility problems, pressure-relieving equipment those prone to pressure sores and the majority of the beds are of the hospital type. The current fee rate is £600.00 for a single room or 615-650 for a room with en-suite facilities. A shared room is £550-575 or £590 for en-suite facilities consisting of toilet, wash hand basin and shower. Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced fieldwork visit was carried out over a period of one day. The manager was not available for the inspection. Assistance was provided by the lead clinical nurse, lead care manager and the administrator. Information was gathered from speaking with people who live at the home and staff. Care, health and safety and the arrangements for medications were inspected. Staff personnel files were checked and staff were observed whilst performing their duties. A partial tour of the premises was carried out. Due to some residents having dementia it was at times not possible to hold meaningful discussions with them. At the conclusion verbal feedback was given to the senior staff who had assisted with the process of the inspection. No Immediate Requirements were made. What the service does well: What has improved since the last inspection? Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 6 A manager was recently appointed and there was evidence of many improvements throughout the home. The new management and staffing structure provides staff with specific roles and clear lines of accountability. There was evidence of an increased involvement of external professions to carry out assessments and give staff guidance regarding specific needs of individuals. The quiet/visitors room has been converted into an activities room. The activities programme has been reviewed and the new arrangements provide people with pleasure and stimulus to enrich their lifestyle. A new type of care planning is gradually being introduced. They offer a much improved system for recording assessments and staff guidance about the care needs that they should provide to promote peoples health. The files also incorporate specific preferences regarding how people wish to live their lives and receive care. Care staff have commenced making daily recordings as well as those completed by trained staff. This ensures that care plans are comprehensive and provide accurate details about peoples needs. A member of staff has been appointed as the lead person for ensuring that health and safety is complied with to prevent people who reside at the home from risks of injuries. The first floor bathroom has recently been refurbished. Upon completion of the treatment room, the old treatment room and adjacent shower room will be converted into another bathroom. Redecoration and purchase of new carpets for bedrooms remains an ongoing process to ensure that people live in a pleasant environment. A new drugs trolley has been purchased to improve the arrangements for administration of medications. The nurse’s office has been refurbished to maximise the available space to hold private discussions with relatives. What they could do better: The home has reduced the daytime trained staff from two to one without consultation with CSCI. It was found during the inspection that this has resulted in people not receiving their medication at the prescribed time. This subsequently means that the prescribed time gap between administration of Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 7 medications is not being met. The problem needs to be resolved promptly to ensure that health care needs of people living at the home are being met. The long outstanding requirement for the implementation of a quality assurance system that includes the opinions of all stakeholders needs to be addressed. This is needed for the home to demonstrate its continuous changes/improvements for the benefit of those persons who reside at the home. Some staff require training in Health and Safety, Moving and Handling, Food Hygiene and Adult Protection. This is required for the home to comply with its category of registration and to supply staff with the knowledge and skills to carry out their roles effectively and to meet people’s specialist needs. 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 Hill Grange Limited DS0000024822.V337905.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 Hill Grange Limited DS0000024822.V337905.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, 3 and 4. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents and external professionals are supplied with comprehensive written details to assist them in making a decision about living at the home. The home gathers sufficient information about the prospective resident to enable the home to demonstrate that it is able to meet the person’s needs at the time of admission. EVIDENCE: Key UI 24/05/07 The statement of purpose and service user guide jointly provide comprehensive information to assist people in making decisions about the home. The emergency procedure was found in the service user guide rather than the statement of purpose however; this does provide people living at the home with essential information about the home. Both documents are presented in large print to make it easier for older Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 10 persons to read them. The statement of purpose is also available in audiocassette format to assist those persons who have visual impairment to understand the services provided. The pre-admission assessments of the two latest admissions were reviewed; both were noted to be well completed. The tool is comprehensive and includes sections for recording mental health abilities, sleep pattern, preferences such as bathing and activities of daily living. A senior member of staff who is a trained nurse is responsible for carrying out the assessments. Staff have not received training in dementia care to provide them with the knowledge and skills to meet the specialist needs of people living at the home. The home does not provide intermediate care but will accept people seeking respite care. Beech Hill Grange Limited DS0000024822.V337905.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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. In practice people’s health care needs were being well met but on occasions this was not evidenced in the care planning. Medications are not being administered at the prescribed time to promote peoples health. Observations of staff indicated that people’s privacy and dignity are being maintained. EVIDENCE: Each person has a written care plan. This identifies physical and mental health conditions, their assessment and details of what staff need to do to promote peoples health and wellbeing. Care plans should be developed as soon as possible after admission and regular reviews carried out to ensure that they address all needs on an ongoing basis. Four care plans were reviewed consisting of the two latest admissions and two of people with varying illnesses. A new process for care planning was being implemented at the time of the visit. There appeared to be a gradual introduction of care plans being left in peoples’ own bedrooms. This provides staff with immediate access to details about what care the respective person needs. The format and content Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 12 of the new system indicated a huge improvement on the care plans seen at the previous inspection. They are comprehensive and peoples personal preferences were noted to be incorporated into them to ensure that staff are sensitive to the way and time in which people would like to have the services delivered to them. Staff also carry out health status assessments such as Waterlow, risk assessments are also carried out and these are reviewed every month. The new system has the potential to cover all aspects of needs and care. Some shortfalls were found that need attention: • The Waterlow assessment of a recently admitted person had not been dated • Some sections of a care plan had been scored through but no date or signature recorded • A person who had a urinary tract infection did not have a care plan in place for this disorder. The home must ensure that short term illnesses have care plans • Where a toileting regime is required they need to be more specific regarding staff instructions. Staff should assess the frequency of toileting that a person needs and record the specific timings to ensure that staff are delivering care that is appropriate to that persons needs • One file had clear instructions for staff to follow regarding assistance with mobilising but no risk assessment had been carried out • Staff must ensure that all recordings made about people who live at the home should be entered into the care plans daily notes. People living at the home gave positive comments to the inspector, “I like living here, its good here”. There was good evidence of the input of various external professionals to assess specific conditions and give staff guidance on how to provide the care needs. This included people’s attendance at hospital appointments as required. The home has adopted a proactive approach to making referrals to external professionals to promote peoples health. There was also good evidence of trained staff seeking a second opinion when they were unsure that a correct diagnosis had been made by a professional. This is viewed as being good practice. The system for receiving, storage and disposal of medications were found to be good. Medications received from the pharmacist were being audited and the results recorded on the MAR (medication administration record) chart before administration to the individual commenced. It was noted that handwritten MAR charts were commenced for people who enter the home with their own supply of medications. These entries must be signed by a second trained person to confirm the accuracy. There was only one trained nurse on duty during the morning when two should have been on duty. It was noted that the administration of the morning medications had Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 13 started early and finished too late for people to receive their medications as close as possible to the prescribed time. This practice is not acceptable, as medications should be administered close to the prescribed time and needs to be addressed promptly. Staff were observed using the preferred term of address to people. Personal care was delivered in the privacy of a bathroom or the person’s own bedroom to preserve their dignity. Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a varied social activities programme that meets the needs of people and provides them with interest and pleasure to improve the quality of their lives. A wholesome and varied diet is offered and specialist diets are catered for. EVIDENCE: A recent review of the activities programme has been carried out. The inhouse programme now offers various activities for six mornings, five afternoons and two evenings each week. A number of staff are allocated dedicated hours to assist with the leisure activities to maximise on their individual skills for the benefit of people living at the home. The programme provides an interesting and stimulating range of activities for those who wish to participate to enrich their lifestyle. The visitors/quiet room has been converted into an activities room and was noted to be occupied by five people who were making bookmarkers and coasters. The carer advised that she would laminate them and apply a ribbon at the end of the session. During the visit two people were observed playing scrabble. An afternoon bingo session was observed during the visit. The organiser is a voluntary worker who carries Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 15 out this role on a regular basis. Other people are invited to the home to carry out movement to music sessions to assist people in remaining as independent as possible. A monthly newsletter is developed and circulated and relatives are encouraged to arrange meetings with senior staff if they wish to. It was noted that a residents meeting had been scheduled to take place shortly and that they will be a regular feature of the services offered. People living at the home are free to come and go as they wish and visiting times are flexible. This was confirmed by speaking to them. Staff advised that a resident was intending to go out to a pub during the evening. Another person goes to a variety of clubs. One person in the home regularly goes to church and another to university. Relatives and friends also take people out. Those who wish to access the community are encouraged and supported to do this to further enhance their lifestyle. A person living at the home commented, “My family come to visit, they are always welcomed”. The food menu was reviewed; it offers balanced and nutritious diets with a good range of choices. Three meals are provided as well as suppertime snacks. Specialist diets are also catered for and the range of meals indicated that culturally appropriate foods were being provided for the current client group. The main meal of the day is served at lunchtime and consists of three courses. Lunch was observed being served; this is carried out over two sittings to prevent people from experiencing cramped conditions. Meals were plated by kitchen staff and transferred to people via a serving hatch. Meals were nicely presented and staff provided discreet and appropriate assistance. The dining room is located in a bright and airy conservatory and dining tables were attractively laid. Sherry is routinely offered at lunchtime. A number of people were noted to be enjoying the alcoholic beverage. The home employs two hostess staff that provides refreshments throughout the day and asks people about their choices for meals to be served the following day. Some comments about the standard of meals were provided, “Food is excellent, the food is always good, the food is lovely”. The tables did not include condiments and staff did not offer them individually. People living at the home should be offered condiments to enhance the flavour of food and to meet their personal tastes. This remains outstanding from the previous inspection carried out September 2006. Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 16 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 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. People who raise concerns or make a complaint are confident that these will be dealt with effectively. Staff must have access to the policy regarding adult protection and receive training to ensure that they possess the knowledge and skills to respond appropriately. EVIDENCE: A copy of the complaints procedure is on display in the reception area and is easily visible. A copy of the complaints procedure is given to each person when they are admitted to the home. There is an effective documentary process in place for logging and investigating complaints. The home had received two complaints by telephone since the last inspection and these had been dealt with promptly and efficiently. No complaints have been received by CSCI since the last inspection of September 2006. The adult protection and whistle blowing policies were being reviewed and were not available at the time of the inspection for staff to refer to if abuse is suspected. Some staff have not received training in adult protection. Two staff members who were spoken with did provide acceptable answers to questions asked about how they would respond to instances of suspected abuse. Beech Hill Grange Limited DS0000024822.V337905.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, 20, 21, 22, 23, 24 and 26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides a warm, homely, comfortable and safe environment for people to live in. Corridors cause restrictions for people who are wheelchair users. EVIDENCE: The home consists of a large detached property that has been extended to provide appropriate accommodation and services for the people who live there. The entrance to the front of the premises has CCTV for security purposes; this does not prevent people from maintaining their personal privacy. The communal areas consist of two adjoining lounges and the conservatory, which is used as a dining room. The secluded rear garden consists of two levels. The upper paved level is accessible from the dining room and has seating areas for people to use during good weather. The lower garden consists of a lawn and shrubs; this provides a pleasant aspect for people to enjoy. The Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 18 visitors/quiet room has been converted to an activities room and was being put to good use. All areas are well decorated and furnished. The home would benefit from appropriate signage to communal rooms and respective bedrooms to assist those people who suffer from dementia in orientating. The current treatment room should move to a new location in the near future to provide more space. Upon completion plans are in place to convert the vacated treatment room and adjacent shower room into an assisted bathroom. This will enable people living on each floor to choose their method of bathing without the need to acccess another floor. Corridors are fitted with handrails but are narrow and restrictive for wheelchair users and there is a lack of designated storages areas. There was an adequate supply of specialist equipment that met the needs of the people living at the home. There are various types of moving and handling equipment to assist staff in the safe transfers of people in the home. There is a call system in all rooms. People who are not able to access the call system in communal rooms are supplied with a call pendant to ensure that they can summon assistance at all times. There are 20 single bedrooms and 8 shared rooms. A wash hand basin and toilet are available in seven of the single rooms and seven of them have shower rooms. One shared room has a wash hand basin toilet and shower room. The rooms of the persons whose care plans were seen were visited. They were found to be tidy and personalised and people are encouraged to take items of furniture as well as personal possessions into the home. Bedrooms were different in size and layout and attractively furnished. A door was found propped open, this puts people at risk in the event of a fire. The home operates a maintenance request book; this is recorded in again by the maintenance operative when the job has been completed. Regular testing of hot water outlets that residents have access to are carried out and the findings recorded. Action is taken if temperatures are outside of the normal range. This protects people from the risk of scalds. The home was noted to be tidy and hygienic throughout on the day of the inspection. In spite of the lack of a chef the kitchen was well organised and hygienic. The home does not have an appropriate disinfectant system in operation for the sluice rooms to prevent the risk of infections. Beech Hill Grange Limited DS0000024822.V337905.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 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staffing levels are not adequate to meet the needs of people living at the home. Recruitment practices are robust and protect people form the risk of harm. Lack of staff training fails to ensure that they are supplied with the knowledge and skills to carry out their roles effectively. EVIDENCE: Review of the duty rota confirmed that the trained staff allocated to daytime shifts has been reduced from two to one. The change was implemented without consultation with CSCI or sufficient consideration given to the outcomes. One trained staff is expected to deal with all clinical issues, any emergencies that arise and the administration of medications. It was noted that to complete the morning medication administrations the trained nurse needed to start early and finish late. This does not ensure that people receive their medications at the prescribed time. The senior staffing arrangements are not acceptable and needs addressing promptly. The recently appointed manager has been requested to carry out a staffing needs review whilst taking into account the numbers and dependency levels of people, the routine tasks and occasional emergency tasks to be carried out. Upon completion of this a copy is to be forwarded to CSCI for consideration and where shortfalls are identified action taken to remedy them. Consideration was being given to implementing a paid handover period for each shift. It is recommended that Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 20 this is implemented because staff have the right to choose not to attend handovers during their own personal time. There is a full complement of ancillary staff to assist care staff in performing their designated roles. At the time of the visit there was a vacancy for a chef, which the home was addressing. Information was supplied by people who live at the home, “I like living here, they treat me well, staff put themselves out in being helpful”. A number of staff files were checked; these suggested that the recruitment process is adequate in protecting people living at the home from risks of harm. It was noted that the appropriate checks are carried out and references obtained before the applicant is offered the position. In excess of 50 of carers had successfully completed NVQ level 2 training. Newly appointed staff will be required to undertake an induction, which mirrors the contents of the Skills for Care programme. Examination of the training matrix indicated that some staff have not received training in Health and Safety, Moving and Handling, Food Hygiene and as discussed previously Adult Protection. Advice was given that this is being reviewed and arrangements to supply the appropriate training will be implemented. Beech Hill Grange Limited DS0000024822.V337905.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): 30, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is experienced and possesses the skills and knowledge to oversee the day to day management of the home. A quality assurance programme needs to be developed to evidence that continuous and sustained improvements are ongoing. Arrangements in respect of health and safety are robust and prevent people form the risks of injury. EVIDENCE: A manager has recently been recruited who has the skills and experience to manage the home and make continuing improvements in the services provided. She has not been registered with CSCI. The home now has a well defined management structure. The lead clinical nurse and lead care manager support the manager in the day to day running of the home. The Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 22 representative of the responsible individual is also present in the home during weekdays. An administrator also works four day per week. The manager or lead care manager work alternate weekends to ensure that people living at the home and care staff teams are given guidance and support. The home was noted to be much more organised and work structured to ensure that staff have clear lines of accountability. Senior staff were observed to be working together fort he benefit of people living at the home. Care staff gave positive feedback about the new management styles and changes that have been implemented so far. No progress has been made in respect of quality assurance since the timescale of 03/08/05 was made. Senior staff have been advised that action to comply with this standard is essential and that further delays will not be acceptable to CSCI. Arrangements for the safekeeping and financial transactions of personal monies that belongs to the people who live at the home are robust. This prevents financial abuse. There are no arrangements in place for people to access their money on Sundays; this needs to be addressed. Regular staff meetings are being held to promote staff knowledge and good practices. Staff formal supervisions have been re-introduced but are not yet fully in place. The home needs to address this to ensure that staff are competent in carrying out their roles. The accident records are good and there is evidence of investigations and action taken where appropriate to reduce the risk of injury of people. All relevant checks and servicing of equipment are carried out to ensure that are fit for purpose. The fire alarm and emergency lighting systems are regularly tested and the findings recorded to protect people from harm in the event of an emergency situation. Regular Fire Drills are carried out and the names of those staff that participated are recorded to ensure that all staff are captured. The arrangements appear to protect people living at the home and others from risks of injury. Beech Hill Grange Limited DS0000024822.V337905.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 3 X 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 3 2 3 3 2 X 2 STAFFING Standard No Score 27 2 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 2 2 X 3 Beech Hill Grange Limited DS0000024822.V337905.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 OP4 Regulation 18(1) Requirement All care staff must receive training in respect of caring for people with dementia commensurate with their experience and records are retained in the home. The training will provide staff with the knowledge and skills to meet people’s specialist needs. Timescale of 28/02/07 has not been met. 2. OP7 15 (1) The process of implementation of 31/07/07 the new care planning system must be completed. All entries must be signed and dated. All persons living at the home must have risk assessments carried out. For those persons who require a toileting regime, staff instructions must be specific regarding timings that meets the individuals needs. Short term care plans must be developed for conditions such as chest or urinary tract infections for the home to demonstrate that all needs are being fully assessed and met. DS0000024822.V337905.R01.S.doc Version 5.2 Page 25 Timescale for action 31/08/07 Beech Hill Grange Limited Timescale 30/09/06 3. OP9 13(2) All hand written MAR (medication 22/06/07 administration record) charts must be countersigned by a second nurse to confirm the accuracy of the recordings before administration commences. People living at the home must receive their medications at the prescribed time. Unacceptable short gaps between further administration fails to ensure that peoples healthcare needs are being met. People must be offered condiments during mealtime to enhance the flavour and to meet personal preferences. The whistle blowing and adult protection procedures must be available to staff at all times to ensure staff have access to guidance when abuse is supected. Completion of the updating the policies needs to be carried out. Timescales of 30/10/06 and 12/12/06 have not been met. 7. OP18 13(6) All care staff must receive training in adult protection and dealing with challenging behaviour. This will assist them in responding appropriately when abuse is suspected. The registered person must ensure that adequate assisted bathing facilities are provided as identified by the dependency levels of people living at the home and to ensure they are DS0000024822.V337905.R01.S.doc 4. OP9 13(2) 15/07/07 5. OP15 16(2)(i) 30/06/07 6. OP18 13(6) 30/06/07 31/08/07 8. OP21 23(2)(j) 31/08/07 Beech Hill Grange Limited Version 5.2 Page 26 given choices about method of bathing. Timescale of 30/08/05 and 30/12/06 have not been met. 9. OP24 23(4) The registered person must ensure all fire doors are kept closed. If there is a need to keep them open they must be linked in to the fire alarm system. Timescales of 20/09/06 and 12/12/06 have not been met. 10. OP26 13(4) The registered person must ensure a suitable sluicing disinfector is fitted in sluice areas to prevent the risk of infrections. Timescales of 3/8/05 and 30/12/06 have not been met. 11. OP27 17(2) Sch4 A review of trained staffing needs must be carried out and any shortfalls identified must be remedied. The review must take into account the numbers and dependency needs of people who live at the home. Upon completion a copy shall be forwarded to CSCI for consideration and agreement. Staff must receive training in Health and safety, Moving and Handling and Food Hygiene. Timescale of 30/12/06 has not been met. 13. OP33 25 The home must develop and maintain a system for reviewing at appropriate intervals of improving the quality of care being provided in the home DS0000024822.V337905.R01.S.doc 15/07/07 31/07/07 30/06/07 12. OP30 13(6) 31/08/07 15/08/07 Beech Hill Grange Limited Version 5.2 Page 27 which includes feedback from stakeholders and development of an annual planning demonstrating outcomes for residents. Timescales of 30/08/2005 and 31/12/06 have not been met. 14. OP36 18(2) The registered person must 31/07/07 ensure all staff receive formal supervision at least six times a year and the process includes all aspects of practice, philosophy of care plus career development needs. Timescales of 30/10/06 and 12/12/06 have not been met but some work has been undertaken towards meeting the requirement. 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 OP14 OP19 Good Practice Recommendations It is recommended that the planned residents meetings are fully implemented. It is recommended that appropriate signage is installed to assist people who suffer from dementia in orientating to communal rooms and their bedroom. It is recommended that arrangements are made for persons living at the home to have access to their personal monies every day. 3. OP35 Beech Hill Grange Limited DS0000024822.V337905.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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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