Inspection on 03/08/05 for Beech Hill Grange Limited

This inspection was carried out on 3rd August 2005.

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

The inspector 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 20/12/05

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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Heathlands

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Inspirations

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

CARE HOMES FOR OLDER PEOPLE Beech Hill Grange Ltd 1 Beech Hill Road Wylde Green Sutton Coldfield B72 1DU Lead Inspector Kath Strong Unannounced 3 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Beech Hill Grange Ltd 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 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 Older People, Dementia (36), Terminally Ill (36) registration, with number of places Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. That the manager succesfully completes the Registered Managers Award (NVQ Level 4 in Care Management) or equivalent by April 2005 Date of last inspection 15 February 2005 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 is currently being further extended to increase the communal areas. The ground floor has a lounge, dining room and a conservatory which is currently being re-built on a larger scale. There is a rear garden, which includes a raised paved area 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 Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 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 progress made since the last inspection. The outcome of the visit was determined by a number of methods. In depth discussions were held with the registered manager, the deputy manager and briefly with the registered provider. Individual discussions took place with five residents and two relatives, also a group activity session was observed. Relevant documentation was examined including four care plans one of which was case tracked in order to ensure that all needs had been fully assessed and met. Written policies and procedures were reviewed. The inspector was also requested to participate in post assessment discussions in respect of two residents. At the conclusion of the inspection verbal feedback was provided to the registered manager and the deputy manger. What the service does well: What has improved since the last inspection? A number of improvements to the premises have been made since the last inspection, including: Laminate flooring has been installed to the perimeter of the lounge and ground floor corridors. The reception area and stairs to first floor have been re-carpeted. Carpets have been replaced in a number of bedrooms and rooms are redecorated as required. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 6 A number of bedroom doors have been fitted with automatic closures, which are activated when the fire alarm is sounded. A larger conservatory is currently being constructed and will be equipped with collapsible tables to enable the room to be utilised for functions. 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 Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3 and 4 Prospective residents are supplied with adequate information about the home for them to make an informed decision. Pre-admission assessments are carried out in order for the home to determine its ability to meet the individual’s needs. When residents needs can no longer be met by the home appropriate action is taken. EVIDENCE: There have been no changes to the service provision therefore the statement of purpose and service user guide remain relevant. A copy of the service user guide is issued to each resident. The home has developed a new contract, the administrator agreed to promptly amend the section regarding the period and means of notice for both parties. An enquiry form is generated prior to senior members of staff carrying out a pre-admission assessment at a venue that is convenient to the prospective resident. The needs of two residents had been identified as beyond the scope and ability of the homes staff. Prompted by senior staff in the home, re-assessment had Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 9 been carried out and established that the home could no longer meet the resident’s mental health care needs. Senior staff advised that they would liase with family members about the need to identify alternative accommodation. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7, 8, 9, 10 and 11 Resident’s health and personal care needs are clearly defined and regularly reviewed within their written care plans. The home adopts a proactive approach to the services of external professionals. The system for the administration of medications is satisfactory. Residents are treated with respect and dignity and their right to privacy is upheld. EVIDENCE: Four care plans were examined. Care plans were found to be comprehensive and included relevant risk assessments, other health assessments and regular reviews. Files included life histories, dietary requirements and preferred routines of daily living and leisure pursuits. Both trained staff and carers maintain records. A resident said, “everything is good”. A relative spoken with reported, “staff are as good as gold, I’m very happy with the standards of care, I have no complaints”. There was ample evidence of the input of external multi-agency professionals. Senior staff were observed seeking information in respect of test results to ensure that appropriate and timely action would be taken. The home has a written policy regarding emergency admission to hospital. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 11 Documentation and practices were examined and determined to be comprehensive. The home has complied with recent legislation in respect of disposal of unused medications and acknowledged that the written procedure needs to be amended accordingly. The privacy and dignity of residents appeared to be promoted and respected by staff. Residents or relatives made no negative comments during the inspection. The home has written policies in respect of death and dying. No changes have been made since the last inspection regarding the extra input by staff, external professionals and regular consultation with relatives. Severe illness appears to be handled sensitively. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 14 and 15 The home provides a varied and interesting activities programme and residents are able to maintain contacts with the community. Residents’ opinions are sought and they are able to exercise choice and control over their lives. The home provides a wholesome and balanced diet including choices. EVIDENCE: The home employs two staff for the provision of an activities programme. One staff member spoken with was currently doing a raffle “because residents enjoy them and one person had specifically requested it”. Records are maintained regarding individual’s preferences, their participation and comments received. The programme included both in-house and visiting entertainers. Residents are encouraged and supported in visits to the community and outings with relatives. The homes administrator chairs the monthly residents meetings and minutes are distributed accordingly. Agenda items indicate that residents influence the day-to-day running of the home. The administrator also spends time each afternoon with residents. As with previous inspections the standard of meals offered and provided is good. Meals are taken either in one of the two sittings in the dining room or Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 13 the residents own bedroom. The lunch being served was well presented with staff offering assistance as required. The home employs two persons who conjointly provide hostess services seven days per week. Their role includes recording of individuals preferred options for each meal. This is viewed as being very good practice. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16 and 18 The home listens to residents and relatives comments and takes appropriate action when a complaint is made. The arrangements in place for the protection of residents need to be more robust. EVIDENCE: The written complaints procedure is on display in the reception area and there was evidence that all complaints however minor were documented, investigated and actioned. The system also includes compliments and how they should be cascaded to relevant people. Since the last inspection there have been two allegations of abuse by two residents. In both cases the adult protection procedures were instigated and full investigations carried out. Neither of the allegations were substantiated but further concerns were raised which the home needed to address. Staff inductions must be completed prior to staff being permitted to work independently and actions taken by senior staff revealed that staff training was not adequate. Positive steps were taken to address these issues, the process of staff inductions have been reviewed, training has been organised for staff but not yet completed. Further action to be taken includes the supervision and training of staff on a shift-by-shift basis and all trained night staff are to work occasional day shifts in order to maintain their skills and knowledge. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20, 21, 22, 24 and 26 Residents live in a comfortable and well-maintained environment but corridors are narrow limiting access and there is a shortage of storage space. There are insufficient bathing and sluicing facilities within the home. EVIDENCE: The accommodation provided is homely and well decorated. There is a maintenance programme in place. Corridors are narrow for wheelchair access and there is an obvious shortage of storage space for linen skips and hoists. It was noted that due to the limited space in the senior nurses office it is impossible to carry out meetings whilst maintaining confidentiality. An appropriate room for such meetings needs to be identified. Communal areas were seen to include furniture, fixtures and fittings of good quality, all of which were well maintained. Advice was provided that the construction of the larger conservatory was well under way and completion would result in greater spatial areas for residents to frequent. The home has an attractive rear garden with adequate seating areas. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 16 The lack of adequate bathing facilities remains a concern. At the previous inspection information was given that the home plans to convert a room into an assisted bathroom and to transfer the treatment room to the unused bathroom. Such action would greatly improve the facilities on the first floor. The premises have been assessed by an occupational therapist and as a result the home was considering the action recommended to be taken. There are 19 single bedrooms 11 of which have en-suite facilities and 8 shared rooms with one having en-suite facilities. All rooms were furnished to the required standard and were personalised to the extent of the occupant’s preference including items of personal furniture. The home has commenced a programme of installing suited bedroom door locks. This remains outstanding from two previous inspections therefore the work must be completed as soon as possible. The home was found to be clean and tidy throughout. There is a written procedure regarding infection control. A relative commented, “the home is always clean and never smells”. Commodes are cleaned in hyperchlorite solution every day. The home must install an appropriate sluicing facility. This requirement was made at the previous inspection. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28 and 30 The staffing levels are inadequate to meet resident’s needs. At least 50 of care staff have attained NVQ level 2 training or above. EVIDENCE: The home has not fully addressed a requirement generated some considerable time ago. This coupled with the current high dependency ratio of residents gives rise to significant concerns. Two nurses must be on duty each weekday morning shift as a minimum and staffing levels must reflect the needs of the current residents. Care staff are encouraged and supported in completing NVQ level 2 or higher training in direct care. The home has recently reviewed the method of delivery of the induction programme. Staff employed to work night duty must complete their induction to the satisfaction of a senior nurse prior to working independently. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 and 36 The registered provider and the registered manager have a clear development plan and vision for the home. A quality assurance system is being developed but has not been put into practice. EVIDENCE: The registered manager has a wealth of experience and skills to carry out her role. A deputy manager supports her and there are clear lines of accountability. The home utilises an open approach and adopts a professional responsive attitude with all staff, professionals, residents and relevant other persons. At the last inspection information was provide that a quality assurance programme would be introduced shortly however this has not occurred. The home must establish an acceptable system. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 19 The home continues with a rolling programme of mandatory staff training. This will be examined in more detail at the next inspection. Formal staff supervision is carried out at least every two months as well as the shift-byshift supervision. All written policies and procedures must be dated, however there was evidence of regular reviews of policies. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 3 2 1 3 x 2 x 2 STAFFING Standard No Score 27 1 28 3 29 x 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 3 2 x x 3 x x Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 9 Regulation 13(2) Timescale for action The written policy in respect of 30th medications must be amended to September reflect the recent changes in 2005 legislation for disposal of unused medications. The home must ensure that the 15th arranged training for all staff October regarding adult protection is 2005 completed. The home must provide 31st adequate facilities to hold October confidential meetings. 2005 The registered person must 31st ensure that adequated assisted October bathing facilities are provided as 2005 identified by the dependency levels of residents. N.B. This remains outstanding from the previous inspection. The registerd person must 31st complete the commenced works October to fit all bedroom doors with 2005 suited locks. The registered person must 15th purchase and install a sluicing November machine that complies with 2005 requirements regarding infection control. N.B. This remains outstanding from the previous inspection. The registered person must 30th Version 1.40 Page 22 Requirement 2. 18 13(6) 3. 4. 19 20 17(1)b 23 (2)j 5. 24 12(4)a 6. 26 23(2)k 7. 27 18(1)a Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc 8. 33 24(1-3) provide two nurses during the daytime (7 hours) every weekday. An audit of required staffing levels must be carried out and submitted to CSCI. The registered person must develop and implement a quality assurance system that incorporates residents views. N.B. This remains outstanding from the previous inspection. September 2005 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 19 Good Practice Recommendations The registered person must give consideration to the lack of storage space for equipment. Beech Hill Grange Ltd E54 S24822 Beech Hill Grange V243106 030805 Stage 2.doc Version 1.40 Page 23 Commission for Social Care Inspection Birmingham & Solihull Local 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. 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